Health insurance Medicare Your Coverage Options

Don’t trust your health plan’s provider directory

Written by Diane Archer

Traditional Medicare’s “one size fits all” approach offers a wide choice of doctors and hospitals at a predictable cost, for which you can budget. 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; and you may not be able to see the doctors you want to see. Beyond that, 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.

If you’re looking to see certain doctors, a plan’s provider directory may list them as part of their network, but the doctors may not be in your health plan. And, if the doctors are in your health plan, they may not be taking new patients from your health plan. Or, the doctors may only be seeing patients from your health plan at a location that is inconvenient for you, which is different from the location listed in the directory. (Here are two tips to help you choose a health plan.)

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. Three years later, the rules are not working.

CMS may 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 they have not. (In November 2014, California levied penalties of $250,000 each on Blue Cross of California and Anthem Blue Cross because 25 percent of the doctors they listed said they did not accept these plans or did not offer services at the listed locations.)

The Washington Post reports that for the third year in a row a CMS audit found that more than half of the Medicare Advantage plans have at least one deficiency in their provider directories–mistakenly telling people that doctors are in-network when they are not or that they are taking new patients when they are not or that they are seeing patients at particular locations when they are not. Yet, the Trump Administration has chosen not to fine Medicare Advantage plans that violate these rules.

If CMS were to use its power to impose fines on Medicare Advantage plans, Medicare revenues could be way up. One recent CMS investigation found that the online directories of 54 Medicare Advantage plans had incorrect information on more than 2,500 of the 5,832 doctors listed. 

Since you can’t trust the provider directory, how can you help ensure you see in-network doctors?

  1. Talk to the staff of the doctors you use to see what plans they are in and whether you will be able to see them in-network.
  2. Keep in mind that three out of ten doctors change their hospital affiliations or practice group each year.
  3. Insurance contracts can be so complex that sometimes staff don’t know what plans the doctors are in. Always call your health plan to double check.
  4. Finally, 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. (Indeed not knowing your future health care needs makes it challenging to choose a health plan that’s right for you.)

Unfortunately, it’s still hard to avoid medical bills from providers who are not in your plan’s network if you are hospitalized. Often the in-network hospital has teams of out-of-network doctors.

Congress is now looking to address the problem of these “surprise medical bills.” Twenty-five states have already passed laws offering people some protection against these surprise bills.  The best way to protect yourself is to let the hospital know in advance of being admitted that you only want to be treated by in-network doctors.

To learn more about Medicare Advantage plan networks and provider directories, there’s a September 2015 report by the Government Accountability Office (GAO) critiquing CMS oversight of Medicare Advantage plans to ensure adequate access to care in the wake of United Health terminating contracts with well over 1,000 Medicare Advantage providers in 24 states. Medicare Advantage plans can end contracts with doctors and other providers at any time for any reason. The GAO recommended heightened CMS oversight of Medicare Advantage plans and rules to help patients accurately understand health plan provider networks.

Here’s more from Just Care:

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2 Comments

  • Is it true that it’s better for a person 60 that’s on SSDI to choose an Advantage Care Plan than Traditional Medicare? I made my decision based on age and unknown cost. I was told it was better for me to wait til I was 65 to choose Medicare, even though I did have it briefly. What concerns me most about Traditional Medicare is the cost of Medigap premiums and Part D. Living on $1400 a month is hard when having to pay all your expenses; rent, utilities, car insurance & repairs, food & etc
    Thank you

  • Be careful with Medicare Advantage plans. They restrict which providers you can use. As pointed out in this article provider networks change. With traditional Medicare and Medigap coverage you are only restricted by which doctors accept Medicare. As for Part D coverage there are subsidies for people with low incomes.

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