As consumers review their coverage and shop for 2017 insurance through the federal health law’s online marketplaces during the annual open enrollment period, many of the directories they are using are outdated and inaccurate. Some doctors in the directories are not accepting new patients and some are not participating in the network, say experts, brokers and consumers. Still other physicians in the directories, who are listed as “in-plan,” charge patients thousands of dollars extra per year in “concierge fees” to join their practices.
“There continue to be inaccuracy problems,” said Justin Giovannelli, a Georgetown University professor, who studies coverage under the health law. Flawed directories are “a real barrier to accessing the care and accessing the insurance consumers have purchased.”
President-elect Donald J. Trump has pledged to repeal and replace the Affordable Care Act, which created the marketplaces. But insurers’ doctor lists are likely to remain a problem no matter what the law looks like, consumer advocates say.
Knowing which doctors and specialists are available within a plan is critical, as patients who visit a physician outside a plan’s network must pay much if not all of the cost.
The effect from flawed directories is even greater this year, as carriers have stopped offering coverage in many markets, meaning many consumers have only one or two insurers to choose from. The number of doctors and hospitals in plan networks also continues to shrink as insurers steer patients toward lower-cost narrow networks.
Reports of inaccuracies suggest that new federal rules to ensure reliable directories are having little effect. Starting this year, all plans sold through the marketplaces are required to “publish an up-to-date, accurate and complete provider directory” or be subject to penalties or removed from the marketplace portal.
But so far no plans have been fined or kicked off the enrollment sites for having poor doctor directories, said Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, which would enforce the rules. A Health and Human Services Department survey of Medicare plans for those 65 and older that was released in October found errors in nearly half of the listings in doctor directories.
Staci Doolin, a co-owner of a radon-testing company in Forsyth, Ill., consulted the Blue Cross Blue Shield of Illinois physician directory in January to make sure her primary care physician was in the network and even called the insurer to double-check.
The directory was wrong. The doctor was not in the plan.
“I thought I was good to go, and then I get this bill and it says my insurance didn’t cover anything and I owe $503,” Ms. Doolin said.
It took until September to resolve the matter — but not before the office threatened to summon a bill collector. She never recovered $100 she spent on a dermatologist who was listed in the directory but who also was not part of the plan.
No comprehensive data exists on doctor directory accuracy. The health law and the Health and Human Services Department set standards for network adequacy but leave most enforcement up to states. States rarely test the lists for accuracy and often rely on consumers to report problems.
But third-party surveys frequently reveal big discrepancies. One recently published study showed as many as a fourth of the doctors listed in California directories last year for marketplace plans were not accepting new patients. About one doctor in 10 was not working for the listed practice.
Consumer advocates often praise California for vigorous insurance regulation. Last year, the state fined one plan $350,000 and another $250,000 for flawed doctor directories.
“I have to think it’s pretty much the same nationwide,” said Simon Haeder, an assistant professor at West Virginia University, who led the study. “Insurers have a hard time keeping these up-to-date because it costs a lot of money, and providers don’t put a lot of effort on giving insurers updated information.”
Even doctor offices are frequently unclear about whether they participate in certain plans, say insurance brokers, who assist consumers shopping for plans.
Confusion multiplies when physicians are in some networks and not others offered by the same insurer. Doctors might be part of broader plan with many choices but not part of a narrow network with nearly the same name.
Directories for specialty physicians may be even more difficult to navigate than those for primary care doctors.
Brian Jarvis, who lives near Dayton, Ohio, needed an orthopedist after straining an Achilles’ tendon this summer. He had to go through 17 doctors listed as accepting his marketplace plan before finding one who really did, he said.
An online tool for Florida Blue, the Blue Cross insurer in that state, does not let consumers search for anesthesiologists, who are often outside coverage networks even when their hospital is in network. Unwittingly being put under by a non-network anesthesiologist can cost patients thousands of dollars.
Even insurers admit patients are ultimately on their own to navigate the directory thicket.
“We recommend you contact the provider to confirm that they are in your plan and that the desired service is covered,” warns the online doctor-search tool for Anthem, one of the biggest sellers of marketplace plans under the health law.
Few consumers take that advice to heart like Ms. Gentieu.
“I was shocked at how awful the state of Ohio is for handling all of this,” said Ms. Gentieu, who was concerned about having a five-year-old hip replacement monitored.
She posted results on her website and sent complaint letters to plans and the Ohio Department of Insurance. Four of the insurers did not substantially dispute Ms. Gentieu’s research.
“While our findings do not exactly match those of Ms. Gentieu, we did identify issues which are being addressed,” said Don Olson, a spokesman for Medical Mutual of Ohio, a health insurer in the state.
Ms. Gentieu found that only 15 percent of those listed as primary care doctors in one Medical Mutual network were actually primary care physicians taking new patients. Many had not accepted new patients in years. Others were specialty doctors, nurse practitioners or medical residents who had not completed their training.
Physicians often fail to tell insurers when they stop accepting patients for certain plans, Medical Mutual and other carriers said.
Like the Health and Human Services Department, Ohio instituted new directory-accuracy rules this year for marketplace plans. But enforcing them is “consumer-driven,” said David Hopcraft, a spokesman for the Ohio Insurance Department. The state does not check the lists until consumers report inaccuracies, one doctor at a time.