By Melinda Beck
Many insurers are offering smaller networks of doctors in their
Medicare Advantage and commercial health plans this year. But those
networks may be even narrower than they seem, physicians and
regulators say, because the lists often include names and addresses
that are erroneous or out-of-date.
In some cases, the doctors shown as participating in plans have
moved, retired or died, surveys show. Others are listed under the
wrong specialty, work in hospitals full-time and don't see
outpatients, or don't accept the plan being offered.
In a study published in JAMA Dermatology last month, researchers
at the University of California, San Francisco, tried contacting
all 4,754 dermatologists listed in the three largest Medicare
Advantage plans in 12 metro areas. Nearly half the names were
duplicates, and only about half the remaining--26% of the
total--were at the listed address, accepted the plan and were
offering appointments. The average wait was 45 days.
"Health plans say it's really hard to keep these lists up to
date--but I just don't buy it," said dermatologist Jack Resneck,
the study's lead author. "When I submit a claim, within a
nanosecond, the plan's computers know if I'm in the network or
not."
Insurers say doctors are contractually obligated to keep them
informed when they change locations or stop participating in
plans.
"There is a shared responsibility between the plan and the
provider to make sure this information is up to date," said Clare
Krusing, a spokeswoman for America's Health Insurance Plans, a
trade association.
Many physicians say insurers aren't responsive to their
complaints about inaccurate listings. In some cases, doctors say it
is the insurer that has dropped them from a network yet continue to
list them in the provider directories.
A year ago, UnitedHealth Group Inc. spurred protests when it cut
as many as 20% of the doctors from its Medicare Advantage networks
in some states. Among those dropped were the 296 doctors who staff
the Moffitt Cancer Center in Tampa, Fla., and more than 1,200 Yale
Medical School faculty members.
But UnitedHealth's Medicare Advantage provider directories for
2015 still list 16 of those Moffitt doctors and 40 Yale Medical
Group physicians as participating in those plans, according to both
groups.
In addition, the 2015 directories list some 275 other
specialists and primary-care physicians as practicing at Yale-New
Haven Hospital, and 39 others at Moffitt.
But UnitedHealth failed to reach contract terms with those
hospitals earlier this year for its Medicare Advantage plans, so
even if those doctors are in-network at other locations, they
couldn't provide in-network hospital care at Moffitt or Yale-New
Haven.
"For consumers, it's very misleading," says Yvette Tremonti,
chief financial officer of Moffitt Cancer Center. "That's what
we're learning as people present for care and we have to tell them
that's not a covered plan."
William Gedge, senior vice president, payor relations, at the
Yale New Haven Health System said: "We implore UnitedHealth to have
these discrepancies rectified immediately for the sake of the
patients who may be relying on this erroneous information."
A spokesman for UnitedHealth said the company would fix any
errors it confirmed. "We are committed to working with health-care
providers, hospitals and other facilities to improve the accuracy
of care provider directories," UnitedHealth said in a
statement.
Medicare Advantage is a managed-care alternative to traditional
Medicare run by private insurers, which covers about 30% of all
Medicare patients. Insurers get per capita fees from Medicare,
which are set to decline in coming years to help pay for the health
law.
Some insurers have cut provider networks to help manage costs,
forcing some members to switch plans to keep seeing their doctors.
The open enrollment period to join or change Medicare Advantage
plans ends Dec. 7.
The Centers for Medicare and Medicaid Services, which requires
that Advantage networks have adequate numbers of physicians in each
specialty, said in a statement: "Medicare is reviewing areas of the
country experiencing provider contract terminations to ensure that
beneficiaries have complete and timely information and access to
needed care."
Similar network-accuracy problems have plagued plans sold on the
health law's marketplaces. Last week, California regulators
released surveys showing that more than 25% of doctors listed by
Blue Shield of California and Anthem Blue Cross as participating in
their health-exchange plans for 2014 weren't at the listed location
or denied accepting those plans.
Both insurers disputed those findings and said survey takers
should have checked to see if the doctors had contracts with those
plans, rather than asking office staffers.
"The law does not require [insurers] to guarantee that providers
and/or their front-office staff members will not be confused about
whether the provider is or is not in the plan's network," Blue
Shield said in a statement.
The California Department of Managed Health Care, which
conducted the survey, said it was designed to replicate patients'
experiences. The agency plans to do another survey in six months to
see if problems it identified are corrected in 2015 networks.
To be sure, some out-of-date listings are vestiges of past
relationships as the health-care industry consolidates. Sometimes
doctors themselves aren't aware that a hospital they practiced in
years ago still has them on a roster and is now part of a major
health-care system that contracts with multiple insurers.
Insurers do tell consumers to check with their doctors to see
what insurance plans they accept. But the answer can be
confounding.
George Hruza says he and more than 20 other independent
dermatologists in St. Louis were cut from UnitedHealth's Medical
Advantage network as of Sept. 1. He appealed the decision and
lost--yet he is listed in its 2015 provider directory, at the
address of a nearby university where he spends only four half-days
a year supervising residents.
He theoretically could see patients in-network there, but not at
his private practice. "For patients, this is very confusing," he
says.
Write to Melinda Beck at HealthJournal@wsj.com
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