The city of San Diego, California is suing Centene, Kaiser Permanente and Molina, three large corporate health plans, for false advertising about the health care providers in their networks reports Health Care Dive. Like many corporate health plans, they are deceiving potential members and cannot be trusted regarding the coverage they provide.
If you have traditional Medicare, you have a wide choice of doctors. With commercial insurance, be it through a Medicare Advantage plan, a state health care exchange, or your employer, your choice of doctors and hospitals can be quite limited. If you develop a costly condition, you might not be able to see the doctors you want to see.
You can’t trust your health plan’s provider directory to reflect accurately the doctors you can use or the locations at which you can get care. Doctors come and go. If the doctors are in your health plan, they may not be taking new patients from your health plan. Or, you may only have coverage from in-network doctors at a location that is inconvenient for you, which is different from the location listed in the provider directory.
People in corporate health plans, who do not have easy access to the doctors they need to see, too often forgo needed care. They endanger their health and well-being. What ‘s worse is that government has little ability to ensure that corporate health plans provide adequate access to care.
In its lawsuit against Kaiser Permanente, Molina, and Centene, the city of San Diego argues that “ghost networks,” health plan networks that are misleading and improperly include out-of-network providers, threaten the public health. But, what leverage does it have to correct this issue even if it wins the lawsuit?
To address problems with health plan provider directories and help people make better decisions about their health plans, CMS imposed rules on health plans that became effective in 2016. Both Medicare Advantage plans and plans in the state health exchanges must publish up-to-date provider directories, including which doctors are seeing new patients, their locations, contact information, specialties and hospital affiliations. And, in addition to making them easily accessible, they must keep them updated each month.
CMS can impose penalties on Medicare Advantage plans up to $25,000 per person enrolled if they violate the rules and up to $100 per enrollee on health plans in the state exchanges. These penalties should deter plans from listing doctors in their directories who have left their plans as much as ten years back, as some have been doing, but CMS has not. The Trump Administration chose not to fine Medicare Advantage plans that violate these rules.
To help ensure a health plan’s in-network doctors meet your needs, talk to your doctors’ staff to see which health plan networks your doctors are in. Always call your health plan to double check. And, make sure that whatever plan you join has a stable of good specialists. Even if you’re healthy, you want to know that there are doctors in the plan who will meet your needs if you develop a costly or complex condition.
Here’s more from Just Care:
- Ten ways Medicare Advantage plans differ from traditional Medicare
- Four things to think about when choosing between traditional Medicare and Medicare Advantage plans
- How to protect yourself from surprise medical bills?
- Inappropriate Medicare Advantage care denials appear widespread
- Judge finds UnitedHealth illegally denied care to thousands
