Under the establishment of the Affordable Care Act (ACA), millions of people have enrolled in new health insurance plans via the health insurance marketplace. When signing up for these new plans, consumers rely on information provided to them by health plans during the enrollment process, specifically the listing of physicians participating with that health plan, referred to as a provider directory.

Recent regulation, litigation, media reports, and independent surveys have resulted in greater scrutiny of allegedly inaccurate or misleading health plan provider directories. What can be done to prevent or rectify inaccuracies, especially since one of the ACA’s primary objectives is to address the consumer’s need for accurate information when selecting a health insurance plan? Are limited resources regarding the maintenance of provider directories, the increasing complexity of insurance products being offered, and the dynamic nature of participating provider information to blame?

A recent whitepaper released by Brian Hoyt, Managing Director at Berkeley Research Group (BRG), examines some of the risks and challenges health plans face in publishing reliable provider directories. To provide deeper insight regarding these questions and proposed solutions,RevCycleIntelligence.com chatted with Hoyt about the risks – and possible repercussions – health plans face related to their provider directories.

As Hoyt recommends within his research, “Health plans should seek to be proactive about achieving and ensuring provider directory accuracy, despite the operational challenges involved in doing so. Given an environment that is increasingly regulatory, litigious, investigative, and putative, health plans should deploy organizational resources at a level that is commensurate with the level of risk that these inaccuracies can present.”

RevCycleIntelligence.com: What types of inaccuracies present the most reimbursement/revenue complications?

Brian Hoyt: What impacts a health plan member most is whether or not a physician is participating with that individual’s health insurance product. If a member needs to see a doctor and they go to their health plan’s provider directory and see a provider listed in the provider directory, there’s a presumption that that particular provider is actually participating with that health insurance product. If that turns out not to be the case, then that member could be hit with a bill for out of network charges.

There’s a trend towards greater scrutiny of these provider directories that health plans are required to publish. Not only are there operational challenges of making sure information is accurate, but there is added pressure of inaccuracies leading to litigation and additional regulatory action.

From a regulatory standpoint, The Centers for Medicare & Medicaid Services (CMS) has mentioned issuing civil monetary penalties and enrollment sanctions against health plans when they don’t get this right. Although there are mitigating factors CMS will consider, in terms of what they identify as a deficiency, it could be any information in the provider directory determined to be inaccurate or deficient in some way. 

If you look at the guidance and start to do the math, those monetary penalties start to add up pretty quickly based on the deficiencies found. The recommendation is for health plans to build to the most stringent standard as established by the guidance and hope they get it right.

RevCycleIntelligence.com: What are the greatest ripple effects of provider director inaccuracies?

BH: As CMS starts to roll out some of these penalties, plans will take them more seriously. There was a recent penalty levied by CMS on Aetna for inaccuracies in its provider information disseminated through one of its call centers. CMS hit Aetna with a million dollar fine, which appeared to be somewhat indiscriminate because there was no real math behind it.

There’s also the added risk of litigation like we’ve seen in California. There are probably close to a dozen lawsuits right now where consumer watchdog groups, classes, or individual plaintiffs are suing health plans over issues stemming from alleged inaccuracies in their provider directories.

RevCycleIntelligence.com: How is the ACA’s greater impact evolving?

BH: The ACA brought to the forefront an attempt by Covered California to collect all this provider information and publish it accurately. There was an effort to publish an all-inclusive provider directory for participating providers in Covered California and they couldn’t get it right. They ultimately pulled the provider directory from the web and directed consumers to the individual directories for each of the participating health plans. 

The idea of trying to publish accurate information is a seemingly trivial task, but when you start to multiply it by hundreds of thousands of providers, it quickly becomes difficult. From an industry trend perspective, you have the three C’s – coverage, consolidation and consumerism. Coverage – the individual mandate in the ACA – is not going away any time soon. We’re starting to see consolidation on both the provider and payer side with the massive mergers of large payers. 

We’re also seeing a consumerism trend. Whether this was a byproduct of the ACA or not is up for political debate. If you think of healthcare costs as price times quantity, since quantity is not going down, you start to focus on price. This consumerism trend is here to stay, as consumers become more savvy about what they’re actually paying for their healthcare coverage. Cost calculators and transparency tools tilt the balance of power towards the consumer.

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