Monday, August 07, 2006

 

The problem with provider directories

Last week WSJ had an interesting article on errata found in health insurance provider directories.
We did some checking to see how well some major insurers are managing. We searched five insurers' online directories by ZIP Code (a common starting point for searches), then called the offices of the first five doctors on each list to verify the phone number and address, as well as whether the doctor is actually in the insurer's network. In some cases, we called other offices in order to avoid, for example, including two doctors in the same medical practice.

While many of the listings were correct, a good chunk of them were completely wrong. Some were more confusing than inaccurate: A common problem encountered is that multidoctor practices can have many locations, which the physicians may or may not rotate among. So searching by ZIP Code sometimes turns up a location where the doctor in question doesn't actually see patients.
Even though their sample size was not very large, the consistency of errors is interesting. And disturbing.

An agent colleague of mine recently fixed a major claims problem for a client. The client's wife was out of town for quite some time and needed to find a hospital to administer a regular cancer treatment. She went online to United Healthcare's website to look up in network hospitals. Eventually, after having received treatment they received a $10,000 bill in the mail. How could this happen? The website told her the hospital was in network. Even the hospital itself confirmed that it was a network provider for United Healthcare. Apparently the issue was that while the hospital was a UHC network provider, it was NOT in network for the member's particular plan. Physician and hospital networks can and do vary by each product offered by insurers. If you have Plan 550, Hospital A is in network. If you have Plan 600, Hospital A is not in the network.

But UHC's network hospital search requires you to plug in your plan. How could it still get it wrong? That's exactly what her agent spent several days trying to clear up. Ultimately he learned that the only GUARANTEED way of finding out if a hospital or physician is in network is if you LOG IN to your personalized UHC member account. Why the public directory search is not accurate is a mystery to me. Clearly UHC should notify all of their members of this problem or work to rectify the issue.

If you can't even trust the online provider search on your own carrier's website, I think we should take that as a sign that healthcare is a little overly complicated. With over complication comes added costs. You do the math.

Comments:
I learned this the hard way a few times. Now, whenever a client wants me to verify that their doctor is on plans I'm showing them, I just call the doctor and ask. You usually have to leave a message and wait, but it's still the only way I'll do it.
 
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