Insurers Facing New Pressure on 'Doctor Directories'

March 1, 2016 by Antonio Arias, MBA, CHBME

Topics: Practice Management, Medical Billing Company

It’s a scenario medical billing professionals know all too well: A patient mistakenly believes a provider is in-network for his insurance and is stunned upon receiving a bill replete with out-of-network charges. 

What ensues next varies – the dispute gets animated; the bill goes unpaid; the collections department gets involved – but it’s never a good situation, for the patient or the medical billing company (or in-house team).

But thankfully, that scenario may begin happening a bit less in 2016. Regulators have wised up to the fact that patients are often trusting more than just their judgment when it comes to choosing a doctor: Insurers often post online doctor directories to help patients know which doctors are in-network for the health plans. The only problem:They rarely update them, leading patients to feel misled into exactly the kind of medical billing issues they attempt to avoid through online research.

Insurers have faced no accountability for such errors – until now. As of January 1, new regulations allow the Centers for Medicare & Medicaid Services (CMS) to fine insurers up to $25,000 per beneficiary for errors in Medicare Advantage plan directories, and up to $100 per beneficiary for errors in plans sold on the federally run insurance exchanges in 37 states.

Given the newness of the regulations, it’s possible they’ll act more like a pre-emptive deterrent than a genuine threat to insurers. But state regulators are pursuing the problem, too, with some big penalties already imposed. California fined Anthem Blue Cross $250,000 and Blue Shield of California $350,000 last November, after a survey found that more than 25% of doctors listed in their 2014 state directories weren’t at the listed location or denied accepting those plans.

Rodger Butler, spokesman for the California Department of Managed Health Care, said that the inaccuracies “limited access to care and resulted in an unacceptable consumer experience” for people of the state.

The move to hold insurers accountable is a smart move for the CMS and state regulators, and a clear show of commitment to making the U.S. healthcare system more transparent, accessible, and consumer-focused. But despite the new penalties, keeping directories up-to-date will be far from easy for payers – especially large ones. The new CMS rules originally called for insurers to contact all network providers every month to verify listings, but the agency revised the requirement to quarterly after both insurers and doctors cried foul. Why?

“The last thing physicians want is for hundreds of health plans to call them every month,” as Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, explained to the Wall Street Journal.

But if physicians and payers collaborate well enough to keep the directors even moderately more up-to-date, patients will benefit significantly from less confusion across the market. And they may not even be the biggest winners: As a medical billing service, we at NCG Medical are certainly hopeful that the new rules will lead to far fewer unanticipated billing disputes that can clog up our clients’ revenue.

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