If you have medical insurance, chances are you’ve become exasperated at some point trying to find an available doctor or mental health practitioner in your health plan’s network.
You find multiple providers in your plan’s directory, and you call them. All of them. But the number is wrong. Or the doctor has moved or retired or isn’t accepting new patients. Or the next available appointment is three months away. Or the provider isn’t actually in your network.
Despite state and federal regulations that require more accurate health plan directories, they still can contain errors and often are outdated.
Flawed directories not only impede our ability to get care. They also signal that health insurers aren‘t meeting requirements to provide timely care — even if they tell regulators they are.
Worse, patients who rely on erroneous directory information can face inflated bills from doctors or hospitals that turn out to be outside their network.
In 2016, California implemented a law to regulate the accuracy of provider directories. The state was trying to address long-standing problems, illustrated by anhealth-exchange-removes-its-physician-directories-because-of-errors.html” data-cms-ai=”0″embarrassing debacle in 2014, when Covered California, the insurance marketplace the state formed after the passage of the Affordable Care Act, was forced to pull its error-riddled directory within its first year.
Also in 2016, the federal Centers for Medicare & Medicaid Services demanded more accurate directories for Medicare Advantage health plans and policies sold through the federal ACA marketplace. The federal No Surprises Actwhich took effect this year, extends similar rules to employer-based and individual health plans.
The No Surprises Act stipulates that patients who rely on information in their provider directories and end up unwittingly seeing doctors outside their networks cannot be required to pay more than they would have paid for an in-network provider.