As uncertainty swirls around the fate of the Affordable Care Act (ACA) and the Republicans’ replacement, the American Health Care Act (AHCA), many patients have only one thing on their mind—finding a doctor who accepts their insurance. For individuals insured under the ACA, either in the state or federal marketplaces or through the Medicaid expansion, increasingly narrow provider networks and lack of choice among insurers makes this an especially important but daunting task.

Penny Gentieu knows this firsthand. She called 308 physicians in six different insurance plans to find a primary care physician (PCP). She discovered that more than three-quarters of the PCPs listed as accepting new patients in her part of Ohio had no openings. Some had not accepted new patients in years, and others listed as PCPs were specialists, nurse practitioners, or medical residents who had not yet completed their training.

Individuals who can’t find physicians in their network resort to expensive emergency department care. Others who rely on the accuracy of provider directories may incur significant costs for doctors who are out of network.

Federal and state laws require doctors to update information about themselves and their practice for each health plan with whom they contract. Failure to do so may result in penalties that range from removal from health plan directories to termination of health plan participation. California has one of the strictest provider directory laws in the nation (SB-137), yet a grand jury report concluded that enrollees in one of Santa Clara County’s two Medi-Cal (state Medicaid) programs found their plan’s directories “confusing and out of date.”

The problem is not specific to California. Harvard researchers seeking mental health care for children in five cities—Boston; Chapel Hill, N.C.; Houston; Minneapolis; and Seattle—found that 22 percent of pediatricians and 26 percent of psychiatrists were not accepting new patients. In nearly a quarter of calls made to psychiatrists, researchers found that the doctor no longer worked there, the phone number was wrong, or the office had never heard of the doctor.

In response to the Harvard study, Dr. Kenneth Duckworth, medical director of behavioral health at Blue Cross Blue Shield of Massachusetts, told the Boston Globe that the insurer will send quarterly reminders to its doctors to update their work status and contact information. Too often, health plans rely on customer complaints to identify and correct inaccurate data.

Uncertainty Creates Challenges

Health plan officials acknowledge the importance of up-to-date provider directories, but also underscore the difficulty in maintaining accurate data. Providers may not give health plans updated information in a timely fashion, and health plans may have a difficult time keeping up with frequent changes. Often, providers are unclear about their role in helping maintain directories, and they may be uncertain about which of an insurer’s networks they participate in. Lack of clarity about the ACA and its replacement only adds to the confusion.

Though few observers believe the AHCA will change requirements that health plans maintain up-to-date provider directories, the current instability and uncertainty in the market leaves much undetermined at this point. In its final rule to help stabilize the insurance market for 2018, the Centers for Medicare and Medicaid Services gives states more leeway in establishing the adequacy of provider networks. If patients are left with fewer choices, their need to have accurate information about the providers who remain available will become even more urgent.

BetterDoctor Can Help!

While health plans and providers grapple with an ever-changing marketplace, BetterDoctor is here to help. BetterDoctor has a singular mission: to deliver accurate provider directory data that ensures that health plans, health systems, provider groups, and doctors comply with all federal and state regulations and provide patients with access to timely, appropriate medical care. Here’s how we work:

  • Health plans share their doctor data with BetterDoctor.
  • BetterDoctor validates the data and proactively contacts providers, using a multimodal approach that includes phone, fax, email, and through existing online portals. Our goal is to use the method most convenient for providers.
  • Validated doctor data is pushed back in real time to health plans.
  • BetterDoctor notifies health plans of validated changes.
  • Health plans quickly incorporate validated data into their member-facing directories.

When accurate information is made available on consumer web platforms, millions of individuals are empowered to make the choices that are best for themselves and their families.

To give your members confidence in their decisions, contact BetterDoctor today. To learn more, you can also visit our website and download our White Paper on The Challenges behind fixing provider directory data.