Health Plan Directory Errors Can be Costly for Patients and Providers Alike

01st Nov 2017
by Laurie Morgan, senior consultant and partner, Capko & Morgan

When a patient moves to a new city and needs to find a doctor, the logical place for them to look is their health plan’s provider directory. After all, patients today typically have insurance – most commonly from their employer, sometimes purchased from an exchange – and they want to be sure any doctor they see will accept their insurance. But even when patients take the time to check their plan directory, there’s a significant chance that the information they find in it could be incorrect. Sometimes, doctors that accept the health plan aren’t listed – so patients don’t know all their options to use their coverage. Other times, doctors who are in the network are incorrectly included in the plan’s directory – increasing the chances that patients will seek services their insurance won’t actually cover. When this happens, patients can end up saddled with thousands of dollars of unexpected bills.

Legislators take notice

This risk of so-called out-of-network errors has prompted recent legislation in many states, including Texas, to protect patients from the cost consequences of inaccurate directories. Under Texas law, if a patient relying on incorrect information published in a payer directory unintentionally receives out-of-network services, their costs are still bounded by the terms of their plan. Copay, deductible, or coinsurance amounts would still be based on the patient’s health plan terms in these cases. Deductible and coinsurance would also be calculated based on the health plan’s usual and customary rate for the services received (not the provider’s fee schedule).

This legislation – and laws like it in other states – can help patients avoid surprise medical bills. But patients must be aware of the rules to benefit: Services must have been received within 30 days of receiving incorrect plan information to qualify for cost protection. And, of course, patients must know that they are able to request action from their health plan if they unintentionally receive services out-of-network. 

Financial cost is not the only risk

Helping patients avoid huge, unexpected medical bills is a big benefit of health plan directory legislation. But surprise bills are only one problem caused by inaccurate directories. When doctors who accept a health plan aren’t listed, patients miss out on the benefit of their expertise. Sometimes, that expertise could have enormous value for the patient’s health and quality of life.

Other types of errors impact patients, too, even if less dramatically. For example, incorrect or outdated addresses are another common directory error.  It’s sadly not uncommon for patients to miss appointments because a directory error led them to an address a doctor hadn’t practiced at in years.

Directory errors harm providers, too

Mistakes in health plan directories can also have a terrible impact on a medical practice business. Doctors who assume that payers regularly re-confirm data are often shocked to learn they’re not properly listed.

For a new physician practice, being omitted from a key health plan directory can be like silently sending prospective patients away. Being wrongly included in a plan directory can also be costly for physicians, since patients may blame them for providing services that aren’t covered, even if the physician didn’t know a directory listing was wrong.  What’s more, as health insurance plan options and narrow networks have proliferated, the potential for errors that has only increased.

Providers and patients should both act to protect themselves

Legislation has helped put a spotlight on the consequences of directory inaccuracy. New laws alone won’t prevent problems from happening, though. Both providers and patients should take steps to protect themselves.

Organizations like CAQH, BetterDoctor, and Availity have launched web tools to make it easier for healthcare organizations to update and verify payer directory listings. By periodically re-verifying listings in these systems as well as in payers’ local and national directories, providers can help patients find care that is covered and reduce out-of-network mistakes.

Medical practices and hospitals can also help patients avoid out-of-network bills by using eligibility checking tools. This software is included in the practice management systems many doctors use; when not available, third-party software can usually do the job. Checking eligibility before the patient receives services avoids billing surprises after care is provided.

Patients can also avoid problems by asking their physician’s office or hospital to verify their insurance when they schedule services. And when in need of an expensive procedure or hospital stay, patients can usually check to see if their coverage applies with a visit to their health plan website or a call to their insurance company.

Preventing out-of-network problems is much better than trying to fix them. Even when the law protects patients against surprise costs, booking an out-of-network provider may mean having to switch physicians while undergoing treatment. At a minimum, this can be a hassle – and most patients will prefer to have continuity of care when possible, especially when dealing with an ongoing health problem.

©2017 Laurie Morgan, Management RX

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