Insurers: Clean up your provider networks


I have a friend, let's call her Amy, who casually told me last week how she struggled to find a pediatrician for her children since moving to our town. She said all the doctors she had called either weren't accepting new patients or "don't take Affordable Care Act plans."

She and her husband purchased a very comprehensive health plan on California's health insurance exchange during last year's open enrollment period. It was cheaper than the coverage they were receiving through her husband's company and the benefits were comparable.

But that's where the similarities ended. Amy was hitting a brick wall every way she turned as she tried to find a doctor who would see her two children. When she initially explained her experience to me, I was surprised. I assumed that doctors understood, first of all, that there is no such thing as an ACA plan.

Then I figured she must be calling doctors who weren't listed as in network. But she said she was referencing her plan's provider directory and reaching out to the ones included there.

After weeks of calling doctor offices, Amy finally found a pediatrician who would accept her plan and see her children. But it was quite the unnecessary hassle that she had to endure to simply make an appointment.

Surprised as I was to hear of Amy's experience, I assumed it was an isolated incident.

And then I read two stories just this week about similar situations. One said that consumers who bought plans through the online marketplaces are having a hard time finding doctors willing to accept them as patients. Doctors have been turning down patients because of payment concerns, already-full practices or administrative hassles related to exchange products. That article pointed out that many providers approach exchange plans like Medicaid, so they're avoiding taking too many patients reimbursed at lower rates so that they don't go out of business.

Just two days later came the news that Medicare Advantage insurers "substantially overestimate" how many in-network dermatologists can treat patients. Many of the doctors weren't actually available--including some that are dead, retired or not accepting new patients, found a study published in the Journal of the American Medical Association Dermatology.

Between doctors who simply don't want to mess around with exchange plans and insurers who are including deceased doctors in their networks, consumers are facing an upstream battle to find providers to treat them.

Of course, the JAMA Dermatology study is limited to just one provider specialty. But given my friend's search for a different specialty and the other story about doctors outright refusing to see exchange consumers, I must admit that I'm concerned.

At the very least, I hope insurers are communicating with their in-network providers to discuss their coverage for exchange plans. That step alone could likely go a long way toward preventing some of this confusion that Amy endured. And insurers also could help their members by streamlining their provider network directories to remove any doctors that can't, or won't, see patients. - Dina (@HealthPayer)

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