KQED in California has been following several of its audience members’ experiences with Obamacare. Today’s story is about finding providers taking insurance and the joys of online provider directories:
I’ve been following Sue Kearney of Oakland. After confirming her doctors would take the insurance, she enrolled in an Anthem Blue Cross subsidized PPO plan with Covered California last fall. Then she scheduled appointments…
But at her first appointment, she was told that the doctor did not accept any Covered California insurance. Ditto for the other doctors. Kearney set up a screen share with me, logged into her account and confirmed for me that doctors showed up as accepting her insurance, but the office said they didn’t when she called them.
That sounds about right.
When I was a young health insurance bureaucrat who did not know any better, I helped to maintain the provider directory. Provider data quality is a constant struggle to get a response from the office manager and the receptionist. If we contracted with a large group, the central office would have a decent idea as to what their CFO or CEO signed but only seven of the thirty four receptionists or office managers were aware of the newest configuration of networks.
There are numerous points for failure in the provider directory informaation chain. The most common is the office manager to health plan link.
Office managers will assume that they have always taken all Mayhew products, so they still take all Mayhew products including the very narrow network, so they tell members that they’re participating in Mayhew Narrow, but they aren’t. Members are shocked when they get billed out of network. Office managers may reflect the attitude of their doctor(s) who are Randian fanboys and assume that they don’t take any Exchange, but their CEO signed them up. Office managers may not be aware that a particular product is geographically restricted, so the office that they work at on Monday, Wednesday and Friday takes the product, but the office that they work at on Tuesday and Thursday can’t take the product. They may also have amazing tacit knowledge which minimizes problems until they retire or move to a different job and the new kid has no clue.
And then they just forget to tell the insurance company about important things:
- The office burned down.
- The office is uninhabitable due to the meth lab next door exploding.
- The provider died two years ago.
- The doctor in question moved three time zones away.
- The doctor in question is in Congress now and no longer practices.
- The office has been bought out by an integrated payer-provider system that does not contract with other insurers.
- The doctor surrendered his license because of a very public front page scandal.
Those are some of the things that providers have forgotten to tell my company.