Tag: Provider directories

Proposed Medicare Advantage rule aims to limit bad insurer behavior
Last week, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, proposed a new rule intended to limit some of the many insurance company bad acts, reports Rebecca Pifer for HealthcareDive. Unfortunately, Medicare Advantage plans all too frequently inappropriately delay and deny people’s care notwithstanding CMS rules. To protect MA enrollees, the government should penalize insurers who violate their obligations severely enough to deter bad acts; without strict penalties, more rules are unlikely to be of much help.

The CMS proposed rule strives to address five of the biggest concerns with Medicare Advantage. The Trump administration will have the power to decide which, if any, of these proposals will be finalized.
- Insurers’ use of artificial intelligence to deny care without consideration of patient needs. The rule is designed to make transparent to MA enrollees their insurers’ coverage policies. Insurers sometimes use artificial intelligence to engage in across-the-board denials of care, even when care is urgently needed. The MA insurers use AI particularly to deny care for people with costly and complex conditions, such as people with cancer and people needing rehabilitation services. New CMS data reveals that more than 80 percent of denials are overturned on appeal, but only four percent of people appeal. The proposed rule also would require insurers to notify enrollees about their appeal rights.
- Insurers’ publication of inaccurate provider directories that misrepresent which physicians and hospitals are in network. The rule strives to ensure that the provider directories do not mislead enrollees as they are wont to do.
- Insurers’ misleading marketing. The rule strives to protect enrollees from misleading marketing.
- Insurers’ coverage of supplemental benefits. The rule aims to ensure that enrollees are fully aware of these benefits and their limitations.
- Insurers’ reporting of how much money they spend on patient care rather than administration and profits. Insurers are legally required to spend at least 85 percent of the money they are paid to cover enrollees on patient care. But, many appear to find ways to spend a lot less.
In addition, if finalized, the proposed rule would for the first time require Medicare to cover weight-loss drugs for people who are obese, even if they don’t have other health conditions.

Here’s more from Just Care:
December 3, 2024
Humana could be penalized over misleading provider directories
Keith Ellison, Minnesota’s attorney general, is trying to hold Humana accountable for misrepresenting the in-network providers in its Medicare Advantage plans, reports Rylee Wilson for Becker’s. It could be the first time that any state has acted to protect their older and disabled residents from misleading Medicare Advantage information. And, it’s about time.

For more than a decade, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, has reported that insurers mislead older adults and people with disabilities through inaccurate provider directories. But, CMS has never done anything to correct the problem, much less penalize insurers for misleading their enrollees.

In Minnesota, Ellison says that people considering joining a Humana Medicare Advantage plan are misled to believe that Humana will cover their care from Essentia Health, Avera Health, North Memorial Health and Sanford Health in 2025. But, all have said that they are leaving the Humana Medicare Advantage network at the end of this year.

In addition to correcting all misinformation in its provider directories as quickly as possible, Ellison wants Humana to detail which Medicare Advantage out-of-network providers it incorrectly listed as in-network this annual open enrollment season. He also wants Humana to protect enrollees who joined based on this misinformation. He argues that Humana should cover their care from these providers.

According to the Minnesota Star-Tribune, UnitedHealthcare also misleads people with Medicare about the providers in its network.

Over the last several months, many health systems have ended their contracts with Medicare Advantage insurers. These health systems not only cite huge administrative burdens they face with MA insurers but also large numbers of inappropriate denials of care.

If you enrolled in a Medicare Advantage plan because you cannot afford traditional Medicare, contact your Senators and representative in Congress. Urge them to add an out-of-pocket cap to traditional Medicare so that it is a meaningful choice for everyone with Medicare, not only a luxury for the wealthy. Only traditional Medicare covers your care from most doctors and hospitals anywhere in the country without requiring prior authorization or otherwise inappropriately delaying or denying medically necessary care.

Here’s more from Just Care:
December 2, 2024
Insurer provider directories misleadingly include physicians who are out of network
Max Blau reports for Pro Publica on how the big insurers provide their enrollees with misleading directories of in-network providers, but nothing is done to fix the problem. We are in the age of tech, when accurate directories should be quick and easy. Insurers should be held accountable if they cannot keep an accurate provider directory, but neither the states nor the federal government is willing to hold the insurers accountable.

Blau explains that insurers are not penalized for inaccurate directories and that it takes old fashioned cold-calling to figure out how misleading a provider directory is. Misleading directories are helpful to insurers since they encourage people to enroll; and, yet, the insurers won’t cover care from the providers they list who are not in-network.

For more than ten years, the federal government has reported large inaccuracies in Medicare Advantage provider directories. Do not assume they are anywhere near accurate and up to date. Providers in the network today can leave the network at any time, and many have been leaving Medicare Advantage plans over the last few years.

New York State government staff called health care providers listed in insurance company directories to determine whether they were actually seeing patients. They wanted to know two key things about the supposedly in-network providers: Do you accept insurance? And are you seeing new patients?

But, the New York State staffers found that lots of physicians who were listed in the provider directories no longer accepted the insurance or were not taking new patients. Some of the time, staff didn’t even get a call back. As it turned out, insurers’ enrollees could not get treatment from more than eight in ten mental health providers listed in directories whom staff reached out to.

The New York State law provides for penalties on insurers who do not keep accurate provider directories. But, New York State rarely penalizes insurers and, when it does, the penalty is tiny. When it comes to provider directories, New York State insurer behavior is no different from insurer behavior in other states. Misleading directories are the norm in most states, including Arizona, California and Massachusetts.

The US Senate Finance Committee staff undertook an investigation a year ago of Medicare Advantage provider directories, and Senate Finance staff also found extremely misleading provider directories. As in the states, the federal government rarely holds the Medicare Advantage insurers accountable.

The consequences of inaccurate directories can be dire for patients who cannot find providers to treat their conditions. For the insurers, it’s more money in their pockets. If their enrollees can’t get care, the insurers keep more money and grow profits.

Here’s more from Just Care:
November 19, 2024
Medicare Advantage networks can be narrow and harmful
If you’re in a Medicare Advantage plan or thinking of joining one, you should worry about two things: Whether you will get the Medicare benefits you are entitled to when you need costly care and whether you’ll be able to use the doctors and hospitals you want to use. Cheryl Clark reports for MedPage Today on a recent Medicare Payment Advisory Commission (MedPAC) meeting in which commissioners criticized the Medicare Advantage networks as ever-changing and often too narrow and harmful to enrollees.

You can’t trust Medicare Advantage (MA) provider directories to list in-network providers accurately. A lot of the time, the listed physicians and hospitals are not, in fact, in network. They’ve left the network. Or, they leave the network midyear. It can hurt enrollees, who lose continuity of care and must scramble to find new providers.

When you buy health insurance, you should be thinking not simply about now but about what could happen to you in the future. Literally anything. A car accident, a fall on ice, a cancer diagnosis, a stroke. You might be away from home. Will your care be covered the way you want it to be in a Medicare Advantage plan? What will you pay out of pocket?

Here are some of problems you can face in any Medicare Advantage plan when it comes to getting a provider to deliver care. These problems don’t exist in traditional Medicare, the government-administered program that covers your care from almost any physician or hospital in the US:
1. The Medicare Advantage plan can leave the Medicare program at the end of any year. And, many have done so in the last couple of years.
2. Physicians and hospitals can leave the Medicare Advantage network. Your care is not covered if you keep seeing these providers. You can pay out of your own pocket to see them or you need to find new providers.
3. In-network physicians might not be willing to see you. They might have too many patients already.
4. Cancer centers of excellence and specialists you need to see might not be in-network.
The Medicare Advantage network directories are very often out of date and inaccurate. Moreover, government oversight to ensure the adequacy of Medicare Advantage plan networks leaves a lot to be desired. Plans know that they can offer inadequate networks without accountability. The government has never penalized a Medicare Advantage plan for offering an inadequate network.

There’s little good about Medicare Advantage networks in practice, though in theory they should help ensure you are getting good coordinated care. Unfortunately, the insurance companies offering Medicare Advantage make more money keeping you from getting good costly care. So, except for some of the nonprofit Medicare Advantage plans, Medicare Advantage insurers’ incentive is to delay and deny you care from good quality physicians and hospitals when you need them.

Here’s more from Just Care:
November 13, 2024
If Medicare Advantage can’t offer adequate provider networks and accurate directories, why are they in business?
People who need health care in Medicare Advantage too often find that the provider directories they rely on when choosing a Medicare Advantage plan are inaccurate. The Senate Finance Committee is looking to address the problem, and the American Medical Association is cheering it on. The fixes are a step forward but should go a lot further. If Medicare Advantage can’t offer adequate provider networks and accurate directories, why are they in business?

For the last 20 years, insurers have been able to make their Medicare Advantage provider network directories look far more robust than they actually are, misleading enrollees. The Centers for Medicare and Medicaid Services, CMS, does not begin to have the resources to oversee network adequacy in the more than 4,000 Medicare Advantage plans, let alone protect enrollees when CMS identifies networks that are inadequate. So, insurers have every incentive to have narrow networks and to mislead enrollees.

The MA plans must know who’s in their network since they pay these providers. There’s no excuse for inaccurate directories. Moreover, the insurers should not be allowed to deceive people by offering different plans with different networks that people cannot distinguish or discriminate against people with low incomes or communities of color by offering them poorer networks than others.

What’s wrong in the network directories? A lot. The directories often fail to explain where enrollees can see in-network physicians (yes, the same physician can be in-network at one location and out-of-network at another,) or they claim physicians are in-network when they are not; and, if providers are in-network, the directories often don’t indicate that they are not taking new patients. It would be easy to fix the problem with one national government directory that imposed penalties on insurers who did not maintain accurate or complete information. One directory would also make it far easier for people to comparison shop for a Medicare Advantage plan.

CMS proposed a national provider directory a couple of years ago, but it has not gone anywhere to date.

But, the insurers oppose a system that would actually help people make informed choices of Medicare Advantage plans. Many in Congress appear to be right there with the insurers. Senator Ron Wyden, who chairs the Senate Finance Committee is trying to end provider directory errors and protect enrollees. Mike Crapo, the ranking Republican on the Committee, claims he is as well. But, what are they doing?

The Finance Committee approved “The Better Mental Health Care, Lower-Cost Drugs, and Extenders Act of 2023,” legislation. Some of it is now law. The bill requires Medicare Advantage plans to have accurate and updated provider directories. Though Medicare Advantage plans always have been required to have accurate in-network information, the bill would require more verification. The bill would also protect Medicare Advantage enrollees from the costs of inaccurate directories if they had to pay for out-of-network care when they were led to believe care was in-network. Beginning in 2026, enrollees would only be responsible for the in-network copay.

Here’s more from Just Care:
June 4, 2024
Ohio and Virginia hospitals warn residents they could stop taking Medicare Advantage patients
If you’re enrolled in a Medicare Advantage plan—a health plan offered by a corporate health insurer—or thinking about enrolling in one, you should be wondering whether you will be able to get the care you need from the hospitals you know and trust. Lots of hospital systems throughout the country, including St. George’s in Oregon, Mercy Health in Ohio, and Bon Secours, in Virginia, are rethinking the value of their Medicare Advantage contracts. We should all be asking our members of Congress why they allow insurers to underpay hospitals and to inappropriately deny care and coverage in Medicare Advantage.

In Ohio, Mercy Health has been in negotiations over its Medicare Advantage contract with Anthem, now Elevance Health, for a while. Mercy Health is not willing to accept the inadequate payments it gets from Elevance any longer. That said, Mercy Health continues to contract with other insurers offering Medicare Advantage.

Similarly, in Virginia, Bon Secours won’t agree to Anthem’s contract terms because of inadequate payments. People in Anthem’s Medicare Advantage plans and Medicaid managed care plans will be out-of-network in October if they use a Bon Secours provider.

Right now, problems with network adequacy in Medicare Advantage are severe, particularly in certain parts of the country. Throughout the US, rural hospitals are closing because of inadequate Medicare Advantage payments. Given that today the government massively overpays Medicare Advantage plans, which will end at some point, access to hospitals for people in Medicare Advantage is likely to get a lot worse.

Moreover, if more people enroll in Medicare Advantage, hospital systems will have less negotiating leverage with the Medicare Advantage insurers. (Traditional Medicare still puts some competitive pressure on Medicare Advantage plans.) And, more hospitals will be forced to accept Medicare Advantage plans’ inadequate payments or close their doors.

Provider networks are one of the many unknowns in Medicare Advantage. They are ever-changing. It’s impossible to know who’s in and who’s out at any given time. Health insurers in Medicare Advantage do not keep up-to-date provider directories, even though they are required to do so. They mislead people to enroll without informing them that they might not be covered for care from the hospitals and doctors they want to see.

Let your representatives in Congress know that they must end the denials and delays of care in Medicare Advantage and protect people with Medicare from disruptions in care because of unstable and inadequate provider networks.

Here’s more from Just Care:
August 23, 2023

You still can’t trust Medicare Advantage plan provider directories

Back in 2019, I wrote a post for Just Care on why you can’t trust Medicare Advantage plan provider directories. Unfortunately, you can’t trust their ads, their sales agents, the quality of the health care providers in their networks or their coverage policies either. You are throwing darts when choosing a Medicare Advantage plan.

What’s particularly disturbing is that notwithstanding years of government oversight identifying untrustworthy provider directories, these directories remain untrustworthy. The Centers for Medicare and Medicaid Services, CMS, which oversees Medicare Advantage, has done little to hold Medicare Advantage plans to account for their failure to keep their directories accurate.

The Senate Finance Committee is looking into Medicare Advantage plans with “ghost networks.” Ghost networks are, as their name implies, haunting and unreal. They are in-network providers listed in Medicare Advantage plan provider directories who are not available to provide care. The Finance Committee issued a report on ghost networks for mental health providers.

No one knows for sure how common these ghost networks are, but Senate Finance Committee Majority staff found a lot of ghosts in a secret shopper study of mental health providers in Medicare Advantage plans. Out of 120 calls staff made, they were only able to make appointments 18 percent of the time. The inaccuracy rate was more than 80 percent. The vast majority of providers listed were either not able to be reached, out of network, or not taking new patients.

Some plans did better than others and availability was better in some states. But, in Oregon, Chairman Wyden’s home state, staff could not make an appointment at all. In Colorado, they were able to make an appointment half the time. In some cases though, appointments were available only many months down the road. Moreover, some offices required additional information before scheduling an appointment; Senate Finance staff could not confirm whether appointments would be scheduled once that information was provided. If not, the provider directories would only have been accurate 13 percent of the time.

Senate Finance is suggests minor steps to correct what can be a huge issue for Medicare Advantage enrollees in need of critical care. It is also a persisting issue. Rather than recommending an open network in any MA plan with inaccurate provider directories–the only fair solution to ensure MA enrollees access to needed care–they want more CMS oversight and financial penalties.

Given mental health parity laws and the fact that one in five adults–nearly 60 million Americans–have a diagnosable mental health illness, access to mental health providers should be easy. Without treatment, people often suffer considerably and can become increasingly ill or even die.

In their report, staff did not name the MA plans they looked into, let alone the names of the worst actors, which would be helpful information for people deciding among MA plans, particularly people with mental health needs. How is it that we know more about differences among restaurants and refrigerators than we do about Medicare Advantage plans?

Here are the Finance staff findings on the rate of ghost listings by state:

Appendix Table 1. Overall and By State Call Results

State	No Contact	Yes Contact	Successful Appointments	Ghost Listings
OH	35%	65%	25%	75%
PA	10%	90%	15%	85%
OR	30%	70%	0%	100%
MA	45%	55%	10%	90%
CO	25%	75%	50%	50%
WA	50%	50%	10%	90%
Total	33%	68%	18%	82%

May 3, 2023

Government proposes national health care provider directory
The Centers for Medicare and Medicaid Services (CMS) is proposing to create a national health care provider directory, reports Allison Bell for Think Advisor. The goal is to ensure that health care provider directories, which are notoriously inaccurate, are kept up to date and reliable. No one should have to spend precious time going through hoops to find a physician their health plan covers.
As proposed, the new National Directory of Healthcare Providers & Services, or NDH would collect accurate information from doctors and other health care providers. In turn, patients would be able to use the database to find in-network providers willing to see them. It would save people a lot of time and energy. It could also help minimize their need to use out-of-network providers at their own expense.

Today, each health insurer keeps its own provider directory. But, health insurers usually have limited provider networks and do a poor job of ensuring the reliability of these directories. Even in Medicare Advantage, health insurers are not penalized in a meaningful way for gross inaccuracies in their directories. However, their enrollees who rely on these directories often find that they have been misled as to the in-network physicians they can see.

Why don’t we already have a centralized provider directory? (For that matter, why do we allow Medicare Advantage plans to have provider networks rather than requiring that they cover care for all providers who accept Medicare?) A centralized government database would hurt the companies that currently are paid to create directories for insurers. But, over the last decade, these companies have shown their inability to keep these directories accurate and up to date. Allowing them to continue is a disservice to the public.

In an audit of health insurer provider directories, CMS found that, in the four years from 2017 to 2021, less than half of the provider entries in these directories were complete and accurate. The directories failed to disclose accurate contact information, health plan relationships, and information on whether the provider was taking new patients.

A centralized provider database would be a good step towards leveling the playing field for consumers, both when choosing a health plan and when trying to identify network providers. It should help ensure people have the information they need.

In the same vein, CMS should create a centralized claims database. Today, information about the services health plans cover (patient encounter data) tends to be incomplete and inaccurate, making it impossible for the government to assess quality, according to the Medicare Payment Advisory Commission. A national database of claims information would not only help ensure collection of accurate claims information, but it would promote public health. The government would be able to see in real time, what services people were receiving, when and where they were receiving them, and at what frequency.

Our federal government has allowed health insurers to set a lot of their own rules for far too long, at far too great a cost to taxpayers and the people who need health care. It’s time to reset the table.

Here’s more from Just Care:
October 17, 2022
Kaiser Permanente sued for misleading people about their network doctors
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:
June 29, 2021
Medicare Advantage: Will you get care from the doctors you want to see at a price you can afford?
It’s Medicare Open Enrollment season in the midst of a novel coronavirus pandemic. If you have Medicare, you should be checking out your options for 2021. And, if you’re planning to remain in a Medicare Advantage plan–a private insurance plan that contracts with the government to offer Medicare benefits–or considering enrolling in one, it’s especially important to look at the tradeoffs you will be making. Once you’re enrolled in a Medicare Advantage plan, it can be far more challenging and costly to get the care you need than in traditional Medicare.

For sure, it’s simpler to enroll in a Medicare Advantage plan than traditional Medicare, public insurance administered directly by the federal government. With Medicare Advantage, there is an out-of-pocket cap, and you can’t buy supplemental coverage to fill gaps. Also, as a general rule, your prescription drug coverage is included with your medical coverage, so you don’t have to buy a separate policy.

But, it’s harder to leave a Medicare Advantage plan than traditional Medicare. In most states, insurers that fill gaps in traditional Medicare, Medicare supplement insurers or “Medigap,” are not required to sell you this coverage except when you first enroll in Medicare or you move. (There are a few other exceptions.) And, many people who need costly health care services, such as home care, nursing home care, or specialty care, find they are far better off in traditional Medicare.

Also, with Medicare Advantage, in 2021, your out-of-pocket costs for in-network care can be as high as $7,550, which the Medicare Handbook fails to mention. On top of that, you have out-of-pocket costs for your prescription drug coverage. In addition, you are restricted in the doctors and hospitals you can use and often need permission from your Medicare Advantage plan–“pre-authorization”–in order to be covered for specialty tests.

A report from the Kaiser Family Foundation finds that more than three in four people enrolled in a Medicare Advantage plan have restricted access to doctors and hospitals. On average, plans offered them access to less than half the physicians in their area. Your access to care depends significantly on where you live and the plan you choose. Fewer than one in four people are enrolled in broad-network Medicare Advantage plans, offering access to at least 70 percent of physicians in the community.

Access to certain types of specialists can be especially restricted in a Medicare Advantage plan. Kaiser found that some plans offer very little choice of certain types of specialists. What’s worse is that it is virtually impossible to know in advance whether you will have access to the doctors you want to use. And, while you might be healthy when you join the Medicare Advantage plan, the whole reason to have health insurance is to protect you in the event that you develop a complex condition and need costly services.

Kaiser looked at 391 Medicare Advantage plans in 20 counties. Its findings assume that the Medicare Advantage provider directories were accurate and that the physicians listed were taking new patients. Other studies have found these provider directories to be wildly inaccurate, and often, providers are not taking new patients.

Here’s more from Just Care:

Medicare ratings of Medicare Advantage plans a farce

Ten ways Medicare Advantage plans differ from traditional Medicare

Four things to think about when choosing between traditional Medicare and Medicare Advantage plans

The Medicare Advantage scam and beyond

Coronavirus: Medicare Advantage plans doing little to ensure their members get needed care
October 27, 2020