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Insurers’ Listings of In-Network Doctors Often Out of Date (The Wall Street Journal)

Insurers’ Listings of In-Network Doctors Often Out of Date Some Physicians Dropped by UnitedHealth Last Year Find They Are Still in Its 2015 Provider Lists    


Updated Nov. 25, 2014 5:28 p.m. ET

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they seem, physicians and regulators say, because the lists often include names and addresses that are erroneous or out-of-date.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.

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