“The impact of inaccurate provider directories on consumers can be devastating, especially on those consumers who need to carefully examine networks for specific subspecialists, cancer centers or children’s hospitals,” the American Medical Association told state insurance officials in a recent letter endorsed by dozens of health care provider and patient groups.But insurers say that the problems might not be easy to fix, and that doctors are partly to blame for the directory errors. Insurers “are unable to guarantee the accuracy of the provider’s status” in a directory because doctors often “stop accepting particular health plans’ members off and on throughout the year and fail to notify the plan in a timely manner,” America’s Health Insurance Plans, the chief lobby for the industry, said in a letter to the Obama administration.
I previously wrote about the volatility within provider networks serving qualified health plans (QHPs) sold on the state health benefit exchanges and how it generates uncertainty that undermines the value of these plans. This New York Times story points to a potential underlying cause: providers exercising discretion at the point of service on whether to accept QHP coverage. Beneath that are likely tensions between health plan issuers and providers over reimbursement rates. Accepting QHPs — which employ narrow provider networks to hold down premium rates — could mean more patients but less income overall for providers relative to the increased patient workload.
As The Times reports, the Obama administration is concerned the uncertainty over the accuracy of provider networks calls into question their adequacy and plans to pressure QHPs in the federal marketplace to update their provider directories at least once a month under the pain of $100 a day penalties for each plan member adversely affected by directory inaccuracies. Pending California legislation, SB 137, would require provider directories be updated weekly.
If plan issuers begin feeling the heat of fines from federal and state regulators, the matter could up in the courts as they seek redress from contracted providers who refuse to honor QHPs. The plan-provider relationship in the post Affordable Care Act environment is shaping up to be major point of friction in the implementation of the law that bears watching closely.
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