It shouldn’t be so hard to find an in-network doctor
Never has it been more important to provide patients with accurate tools to help navigate our fragmented healthcare system. At my hospital in New York City, we discharged hundreds of previously healthy COVID patients, many without regular doctors, now in need of care to manage the lingering effects of their illness — shortness of breath, kidney damage, depression and anxiety, among many others. Others have had their coverage disrupted due to changes in employment and need to find new doctors.
Many will have difficulty obtaining care because of a lack of insurance and provider shortages. Even for those lucky enough to have insurance and enough doctors in their area, finding a new in-network doctor or provider can be surprisingly difficult. The basic tool for finding a new doctor — the insurance provider directory — is often flawed and list providers as in-network that no longer take the insurance or are not taking new patients.
Accurate provider directories are critical. Directories can help patients find in-network providers in a convenient location, that speak a specific language or provide specialized services. Patients may use the directory when choosing a new insurance plan to ensure that their doctor or a preferred hospital are in-network. Directories are also used by regulators to ensure that insurance companies have adequate networks. If a directory incorrectly lists doctors that don’t take the insurance or are not accepting new patients, regulators may certify that an insurer is supplying enrollees with enough in-network providers when this isn’t the case.
Yet, outdated information and other errors are common in directory listings. Studies have found directory problems with Medicare Advantage, Medicaid managed care, and some Marketplace plans. Even in private plans — those most likely to have adequate resources — patients encounter problems. We conducted a national internet-based survey with adults with private insurance on their experiences using insurer directories. In our survey, we found that 12 percent of privately insured noted errors with fundamental directory information — whether a provider had correct contact information or was correctly listed as taking the patient’s insurance.
The consequences of outdated directories can be more significant than just wasted hours on the phone and frustration. In addition to causing delays in care or even lack of care, outdated directories may result in surprise bills or unintentional care from an out-of-network provider.
While most associate surprise bills with an emergency room or out-of-network providers at in-network hospitals, they occur with outpatient providers as well and are often not reimbursed. In our survey, 39 percent of visits to outpatient out-of-network providers were associated with surprise bills. Those reporting a surprise bill were also more likely to report a directory error. Most out-of-network visits (71 percent) were not reimbursed by the insurer, usually due to no out-of-network coverage or having an unmet deductible.
Incorrect directories are particularly important for mental health care. Job loss, loss of loved ones, and the isolating effects of social distancing related to the pandemic are all expected to increase the prevalence of mental health symptoms and the number of individuals seeking mental health care, in some cases, for the first time.
Telehealth, which has been more quickly adopted in mental health care and recently expanded due to the pandemic, may further increase the importance of directories as a tool for locating services. While a patient could rely on recommendations from friends or family members to find local mental health providers, these referrals may miss available telehealth providers located further from home. Not surprisingly, directory errors are also common in mental health. In our survey of privately insured, we found that 36 percent of patients using their mental health directory encountered errors.
Some states have laws requiring private plan directories to be updated, yet they vary in scope and may not apply to some self-funded employer-sponsored plans. States also rarely enforce penalties for network adequacy violations, which include directory errors. Enrollees in Medicaid managed care, Medicare Advantage, and Marketplace plans are protected by federal rules that require these plans to provide regularly updated directories with standardized information, though errors are still common.
The COVID-19 pandemic has amplified all the sore points in our health care system — an uncoordinated and underfunded public health infrastructure, racial inequities, and fragmented healthcare delivery and reimbursement. To be sure, provider shortages, unemployment, and other barriers to accessing care are critical issues that need to be addressed to help patients recovering from COVID get the care they need.
But improving the accuracy of directory information is one step that policymakers can take now to help patients. Closer monitoring of directories by state and federal regulators, a federal standard for directory accuracy for privately insured, holding insurers liable for directory errors, and improving outdated directory data technology are potential strategies. Providing patients with the basic tool they need to find help — an accurate list of available providers — is a first step in addressing this problem.
Kelly Kyanko M.D., MHS, is an assistant professor at NYU Grossman School of Medicine and Susan Busch, Ph.D., is a professor at Yale School of Public Health.
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