The ACA (Affordable Care Act) has significantly increased the number of consumers participating in an already overburdened healthcare delivery system.  While it has provided significantly increased access to a wider range of health insurance benefits than has ever before been available, it has also added increased complexity.  The onus is on health insurance providers and payers to provide networks sufficient to meet the needs of their enrollees and resources to help both provider end consumer navigate complex benefit plans.  While the ACA provides guidelines for the adequacy and accuracy of provider networks, states are responsible for ensuring these guidelines are met.

Inaccurate and inadequate provider networks in the exchanges have been in the headlines frequently in 2014 (ACA EXCHANGES CAUSING UPTICK IN PROVIDER DIRECTORY ERRORS – and are the driving forces behind actions like the introduction of CA SB 137, proposed by State Sen. Ed Hernandez (D-West Covina) that would require insurers to improve and frequently update their provider network directories.  But anyone involved in managing provider networks post the (HMO) Act of 1973 knows the chronic pain of providing accurate participating provider data. Many regulations regarding accuracy of provider directories date from the age of paper directories and have little relevance for protecting digital age consumers searching online provider directories.  Constant maintenance of this data is a significant expense for any kind of health plan.

Details of SB 137

SB 137 would require insurers to:

  • Update their provider lists weekly and make that information available online for consumers;
  • Post online whether in-network physicians are accepting new patients; and
  • Publicize what languages their in-network providers speak.
  • It also would require state regulators to develop a standard format for provider directories.

The bill is sponsored by:

  • The California Pan-Ethnic Health Network;
  • Consumers Union; and
  • Health Access (Los Angeles Times, 1/23).

The Senate Health Committee will consider the bill in April.

If the California bill (SB 137) passes, the Golden State, will join the ranks of Illinois, New Jersey and Washington, with specific requirements to keep provider network directories current.  With rumblings from consumer advocacy groups in states like New York, Florida and Georgia, it is no great stretch to expect similar legislation in the near future.

This movement is understandable given the less than stellar customer experiences reported.  Participating provider data is some of the least accurate data a consumer is presented with and yet ensuring their providers are in network is a significant purchasing influencer when selecting a plan through the marketplace.  Consumers also have to visit multiple sites to pull together provider and benefits info.  Although consumers indicate their willingness to participate in narrow networks for reduced premiums, lack of accurate information turns this into a nasty surprise in the form of out of network bills.

Providers also face challenges in exchange plans.  They are often left with the burden of educating patients on their participation and have difficulty verifying their participation in exchange plans. The American College of Physicians encourages practices to be proactive and verify with insurers whether or not they are included in their marketplace-based insurance networks.  Likewise, consumers are advised not to rely solely on the lists provided by insurers.

What’s a Health Plan to Do?

If the idea of issuing weekly, accurate provider updates strikes terror in to your heart, you are probably not alone.  Insurers and health plans who succeed in today’s marketplace will:

  • Create online and mobile tools that allow members to find in network providers easily and track scheduled appointments
  • Synchronize and communicate plan data to both providers and members
  • Enable members to verify their copays and deductibles relative to the provider they plan to see before service is provided and in real time
  • Proactively communicate with members on plan usage, changes, benefits
  • Centralize providers’ ability to update their demographic and network participation information to a single portal
  • Easy access for providers to eligibility, benefits, copays and deductibles and networks for referrals in real time
  • Get a jump start on quality ratings – proactively prompt members for ratings post appointments

There are a lot of ways to come at this problem. Whether you invest significantly infrastructure or look to partner with a data expert, it will be critical to put that data in the hands of your members and help that understand what it all means.