As an increasing number of U.S. residents gain access to health coverage through the Affordable Care Act, many turn to network directories to determine which plan is best for them and to find a provider affiliated with their coverage. Inaccurate or outdated provider directories could throw a wrench in those plans.
However, improving the directories has posed business, operational and technical challenges for many stakeholders. So the California HealthCare Foundation and Manatt Health looked into how four states have overcome such obstacles, with the “goal of informing California policymakers and stakeholders as they seek to improve consumer access to accurate provider network information.”
In a study released by CHCF — publisher of California Healthline — and Manatt last month, researchers examined the experiences of consumer advocates, insurance carriers, providers, exchanges and Medicaid agencies in California and four other states — Colorado, Maryland, New York and Washington — to determine best practices for overcoming challenges related to network directories.
Importance of Accuracy
The study notes that “many consumers are making health coverage decisions for the first time and in new ways” in the wake of the ACA. Provider directories — electronic or printed lists of health care providers who are part of a health plan’s network — often contain inaccuracies, which “can lead to consumer frustration and confusion, and result in substantial out-of-pocket costs for consumers who may unintentionally seek and receive out-of-network care,” the researchers wrote.
According to the study, directories “should engage and inform consumers with diverse language needs and educational levels as they enroll in coverage and seek care.”
Challenges To Improving Directories
Despite the large role that provider directories have in helping consumers make health care and coverage decisions, insurers, Medicaid agencies and insurance exchanges face several challenges to maintaining network provider lists, according to the study. The problem stems from:
- The frequency of network changes, such as when practice locations open or close and changes to contracts;
- A lack of uniform data and communication standards for transmitting changes between providers and carriers, which can result in unusable data; and
- A lack of strong incentives and enforcement methods that require regular updates.
In particular, “[l]ack of enforcement of regulatory and contractual requirements created an environment that does not foster shared accountability,” according to the study.
While “all of the target states examined for this project and California have passed laws or regulations requiring carriers to maintain accurate provider directories … there has been limited to no regulatory enforcement or penalties issued to carriers for failure to maintain accurate directories” in most states, the authors wrote. “As a result, there are few incentives for institutions to invest significant resources to maintain directories or to penalize contracted network entities for failing to meet contractual obligations to provide them with necessary information.”
Stakeholders who participated in the study said penalties often are not enforced “primarily out of concern for compromising robust provider networks and the mutual interests of state Medicaid agencies, [exchanges] and carriers to minimize disruption of member services,” the authors wrote.
Takeaways for California Legislators
Aligning Policy, Regulations with Enforcement
The study found that policy and regulations often lacked adequate enforcement actions. As a result, the researchers say, “Regulators and public and private policymakers should consider how they convey consistent guidance and policy coupled with enforcement to set clear expectations for carriers.”
They wrote that such a focus “is especially relevant in California, where misaligned or conflicting policies across regulators, major purchases and agencies could result in confusion and inefficiencies for carriers.”
Implementing Standards, Accompanying Guidance
The researchers also found that California “could be well-served through continued development of a single template” for collecting data to support provider directories “coupled with detailed guidance, agreed-upon standards and nomenclature of required data fields,” as well as “robust data submission and verification process.” The authors noted that “carriers, Covered California and Medi-Cal rely on self-reported provider data and disparate sources against which they check provider information for accuracy and to identify if providers are sanctioned.”
According to the study, California policymakers also should consider “whether there is sufficient demand to develop a reliable, centralized resource of provider information.”
Considering Health Care Resources, Population Diversity
Meanwhile, the authors wrote that “[t]he sheer size of California and the diversity of its health care institutions also have significant implications for the resources required to adequately establish and maintain accurate provider directories, especially any centralized efforts by the state or marketplace.” They cautioned that lawmakers and other stakeholders should not underestimate the “size and significance of California’s health care landscape,” adding that “at the state and marketplace levels, it will be a significant task to create and maintain more accurate provider directories, requiring an investment in resources and a commitment from leadership to prioritize provider directory efforts.”
A Focus on Helping Consumers
To successfully inform consumers seeking to enroll in coverage or obtain health care services, provider directories “must be developed with the consumer in mind and consider the way consumers think about and experience the health care market,” according to the authors. “Stakeholders designing and implementing directories should consider how to best serve consumers with low levels of health literacy to meaningfully inform their decisionmaking.”
Directories also “should take into account and be responsive to the heterogeneous needs of California’s diverse population,” the study suggested, adding, “Primary language, cultural norms and the specific needs of people with disabilities all factor into consumer decisionmaking in the health care arena.”
The Importance of Safeguards
And finally, the authors wrote that “when consumers buy an insurance product based on a provider director network listing that may have inaccuracies, adequate financial protections and a clear process for recourse for consumers can be put into place.”
They suggested that stakeholders provide safeguards to consumers who “encounter and make decisions based on incorrect provider directories,” such as:
- Offering special enrollment periods for such individuals; and
- Providing coverage for out-of-network care.
In addition, the authors wrote, “More can be done to make certain that assisters, brokers and health plan personnel understand that provider directory errors trigger specific recourse for effected consumers and encourage them to take action so that consumers receive the health care services they need.”
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