<p>Our insurance broker was right. Thank goodness we bought a plan for our small business that isn’t from the Marketplace. While the ACA plans in other states and areas may be suitable for many, the plans offered in our area absolutely stink. I feel bad for anyone in our area who finds themselves stuck with a plan from the NYMarketplace. Good luck finding a doctor (or hospital for that matter) that accepts it.</p>
<p>“According to the Department of Managed Health Care, the insurers aren’t breaking any laws. They are only required to update provider lists quarterly and those lists are subject to change at any time.”</p>
<p>I love this. I assume it is just the general governance of insurance companies already in place which ACA did not change but I would prefer they show fewer rather than more doctors if they are allowed so much variation.</p>
<p>"Dana Howard of Covered California admitted it was responsible but said, “It really isn’t feasible for Covered California or any entity to check thousands upon thousands of doctors to make sure that the information that they are providing is accurate.” </p>
<p>“Covered California is suggesting enrollees to first talk to their insurers about finding alternate doctors. But if they’re still unsatisfied, they can cancel before the end of open enrollment on March 31, 2014.”</p>
<p>This is so typical of Covered California. It’s why you can’t believe any of the BS coming from them. They are a propaganda arm of the govt, only concerned with getting anybody who can breath to sign up for an exchange plan.</p>
<p>I have to laugh at their proposed solution of telling enrollees to call the insurance companies about finding alternate doctors. Guess where Covered Ca is getting their screwed-up information. As for calling them, that’s the biggest joke of all.</p>
<p>Edit: Texas, the provider directories were accurate before Obamacare.</p>
<p>Whether or not provider directories were accurate before, they need to be accurate now. Some of this brouhaha is shining a light on bad practices that need to be corrected, and should be corrected whether there is an ACA or not.</p>
<p>Insurance companies easily have the capacity to keep their on-line directories up to date in essentially real time – it’s a simple database issue, something that can be updated as a matter of routine as paperwork gets submitted to whichever unit within the insurance company is responsible for tracking provider status and enrollment. In other words, if Dr. A. submits an application to Anthem to join Networks A and B, but not C, then at the same time Anthem processes the signed contract, the database can be updated to add Dr. A’s information. It really can all be managed by one central database-- if the main database is off line (good for security reasons), it can be programmed to automatically sync up with the online database every night at midnight. </p>
<p>For the exchange to track them all is a different problem – rather than keeping all that information online at the exchange, a better solution would be an exchange-based search engine that automatically searches the data that each insurance company has online – kind of like Kayak works to provide up-to-date listings of airline fares. IF all the insurance companies had their provider data online and current, then it would be a simple task, to design the centralized “search all” feature, because there are not that many companies to track. Even if their databases were structured differently, there are still a manageable number of queries to run. </p>
<p>If the exchange was running queries using API’s to connect to the insurance company’s databases, rather than trying to manage its own list, that would remove a significant (and costly) administrative burden from the exchange, and potentially provide more up-to-date information – and at least put the burden on the insurance companies where it belongs. But at the same time the information could be accessed from a centralized feature on the Covered California web site. </p>
<p>^ I would think this is how a system would work, Either they build a trawler like Kayak or simply provide a link to the insurer’s website as opposed to trying to manage multiple sets of data when they are at the mercy of the insurer to be accurate. </p>
<p>What I don’t get is the insurer having 90 days to update the entries. They have kicked off a brand new program and they are expecting millions (at least dstark says so!) to be using these lists. How hard is it for the insurer to be accurate 99% of the time about who is in their network? Did Anthem singlehandedly bring down the value of online lookup system?</p>
<p>Well, that isn’t the way the contracts work in many cases, calmom. A practice (consisting of multiple providers) may be contracted, or individual providers in a practice may be contracted for that location. Providers practicing out of multiple locations (not uncommon with specialists) may be contracted at one location and not at another. Some are contracted but not accepting new patients with that insurance (but still seeing legacy patients with that insurance), and these days many practices are owned by hospitals, and the doctor’s practice isn’t directly contracted – it is the hospital that is contracted. Other large groups of physicians band together in an IPA, and anyone joining the IPA is automatically in-network for all the IPA’s contracted providers. Providers that leave a contracted practice to open a new office don’t carry the contracted status with them, and it can take months to get that status cleared. </p>
<p>I don’t know why there hasn’t been more effort to date in building accurate provider directories, but they suck. The search mechanism is even suckier, especially if you’re searching for something other than a physician. It is still a giant suck at United Healthcare, and was at Anthem too. The suckage didn’t matter as much when the networks were very, very wide, but with narrow networks it poses a real problem. The feds or state regulators lighting a fire under the insurers about this would be a very good thing. </p>
<p>My professional experience (and D’s current professional experience!) is that front office staff at a doctor’s office are unreliable narrators when it comes to determining whether they are in-network for a specific insurer, plan and sub-plan.</p>
<p>Trust, but verify.
Look up the provider in the on-line directory & see what location(s) are listed. Do a screenprint.
Call the doctor’s office and ask to speak to the person who handles billing and insurance. Way more likely to get accurate information from that person (who might be in a completely separate office) than from the front office staff.</p>
<p>I’ve used the screenprint to get in-network payment when United decided that one of D’s providers wasn’t really in-network. It worked. </p>
<p>I’ve also use the state insurance commissioner to light a fire under United when they wouldn’t provide an accurate formulary, and I’d do the same if a listed in-network provider turned out not to be contracted. </p>
<p>You know the “Don’t Tread on Me” flag? I’ve pretty much got that flying when it comes to health insurers. </p>
<p>I have noticed that most parents here are ridiculously over educated (I would say top 5% in education based on how many have advanced degrees). Many of us seem to discuss esoteric issues in ACA but I think the most fundamental issue being cost, nailing down in vs out would be something that really helps the people out there (my guess is ACA too).</p>
<p>I love arabrab’s self-protection methods (truly esoteric). </p>
<p>I am worried for the common man who has no clue about any of this.</p>
<p>arabrab – you are still describing a database entry issue that can be managed by the insurer – they just have to design the database to distinguish among individual providers under contract vs. group practices that carry the contract, and be able to store multiple locations, as well as whether or not the provider is accepting new patients and any other info they feel is relevant for their database. </p>
<p>The insurer knows whether the provider is currently in-network or not – they HAVE to know that info, because they can’t process a claim without it. </p>
<p>And it is far more efficient for any system to do updates to either keep everything within a single database, or automate their systems so that entries into the main database are automatically pushed out to subsidiary databases that rely on that info. </p>
<p>Yes, worried about the common man. And many of the anecdotes we hear are those folks. Includes buying on price only.</p>
<p>Yes, you can code whether a doc is contracted as an indiv or the group is. And code for location. And not that hard to make it all sortable, in at least a few ways. (well, you know I have this for my carrier.)</p>
<p>The issue is accuracy. Best sw in the world is no good without accuracy. </p>
<p>Calmom & lookingforward – you’re right. We figured out years ago that the fundamental unit was a specific provider at a specific location. They shouldn’t have too much problem managing the database of providers that directly contract. The cascading contracts that flow on based on provider affiliations (like hospital ownership, IPAs, Clinic Groups like Planned Parenthood that employ providers) are more of a challenge, and for whatever reason, the insurers have not dealt well with the directory database design issue. </p>
<p>I can’t specifically speak to today, but the provider directory databases in the past were not linked to the claims software – and that introduces other discrepancies. The companies put a lot more effort into the accuracy of claims software than they do in the provider directories. At least back then, provider directory information was strictly a cost area, claims management software was a key profit/loss area for insurers. You can imagine what got more attention.</p>
<p>So it sounds like fines for wrong provider directory information could be in order-- then it would be a profit/loss area. Or at least a loss area.</p>
<p>“So if the insurers are not accurate and the front office staff can’t tell the patient, how do the subscribers know who is in their network?” </p>
<p>There is a very simple answer to this question pre-Obamacare. Just about every doctor and hospital in Ca were in the network for the major insurance companies. It was the exception not the rule when someone was not in-network. Today, it is the opposite for these exchange plans.</p>
<p>For instance, I have a group plan with a legacy network. It includes just about every provider in California. This issue is not a concern for me.</p>
<p>I have had individual PPO insurance in Ca. for 26 years. Trust me, this wasn’t an issue in the past. It has become a major issue because of the narrow networks for exchange plans. </p>