Health insurers publish provider directories for patient use. But are they accurate?
The state’s largest health insurer recently hired more staff to update its provider directory and introduced new features to help providers enroll faster.
Blue Cross and Blue Shield of North Carolina has “experienced a significant increase” in providers asking to be added to its provider directory or update their information since late last year, according to spokesperson Kyle Marshall.
Why does this matter? Immediate access to accurate information on health care providers is vital to people needing medical care, experts say. Consumers must know who is in an insurer’s approved network, whether they’re taking new patients and where they are located.
But sometimes the information available to patients is incorrect.
When the Charlotte Observer checked information about 50 Charlotte therapists listed in a Blue Cross NC provider directory, for instance, not everything was accurate.
Health insurers “are committed to ensuring their members have access to a comprehensive provider network, and that the information in our provider directories is accurate and timely,” said Peter Daniel, executive director of the North Carolina Association of Health Plans.
Still, consumers should know what shortcomings can occur and look out for them, experts say.
Ghost networks
Inaccurate directories are sometimes called “ghost” or “phantom” networks, and they’ve caused problems in North Carolina.
Patients who choose providers from insurance directories assume those providers are “in-network,” which means they accept their insurance coverage.
If a provider doesn’t actually accept that plan or only accepts it at certain locations, patients may inadvertently go “out-of-network.” Insurers don’t want to pay as much for visits to providers that don’t have contracts with their plan, so patients can end up with higher costs.
Last year, an eastern North Carolina resident chose a provider from the online Blue Cross directory only to find out after an appointment the provider didn’t take her plan at the hospital she went to, according to a complaint filed with the state Department of Insurance.
“This discrepancy is potentially causing me to incur a bill that is approximately $5,000 more than what I had anticipated,” the patient wrote.
The complaint was eventually resolved, with Blue Cross deciding to cover the appointment, according to a letter from the insurer to the DOI obtained by the Observer. But what happens to most patients who find themselves in this situation is not clear.
A federal law banning surprise billing went into effect in January, but a national survey from research company Morning Consult found that one in five participants reported receiving unexpected out-of-network charges in 2022.
That could add to an existing burden in North Carolina, which has the sixth-highest share of residents with medical debt according to an analysis by the nonprofit Urban Institute.
Not accepting patients
Sometimes providers may be in an insurer’s network but they’re unavailable. They may not be accepting patients, may have moved locations, or may even be deceased, as one psychiatrist documented in STAT News.
The Observer identified 50 Charlotte therapists from a Blue Cross NC provider directory and fact-checked the information on their listings by contacting them and searching for their practices online. Most listings were correct but some had multiple errors.
Only one therapist was listed in the Blue Cross directory as not accepting patients. But at least two more were not accepting patients and two others had a wait list. At least 17 were listed at locations they no longer worked at. At least two no longer accept Blue Cross. One therapist even had the wrong gender listed.
Identifying the reason for outdated information can be complicated.
Charryse Johnson, founder of Jade Integrative Counseling and Wellness in Charlotte, explained that it sometimes falls on health organizations. Her office location was outdated on the Blue Cross NC provider listing as of July 27.
She was listed in two locations: Jade Integrative Counseling and a location she left in 2019.
When providers start taking insurance at a specific location, insurers add them to a list of in-network providers at that location based on information the organization provides. These lists inform what goes in provider directories.
If a provider leaves a practice, that practice is supposed to notify the insurer. But that doesn’t always happen, Johnson said.
Inaccurate information can make it harder to find care in places like Charlotte, where there aren’t enough mental health providers to adequately serve the population according to the Health Resources and Services Administration.
“You call five and they don’t call you back. You call five more and they’re all busy,” Johnson said. “By the time that’s all said and done, most people are like ‘I give up.’”
Providers can submit changes to their Blue Cross listings by submitting updates to a designated email address, said spokesperson Jami Sowers. The insurer also reaches out to providers quarterly to verify their listings.
“In accordance with new federal requirements, we will display changes providers share within two days of notification and remove providers from the directory who do not attest that accurate information is displayed every 90 days,” said Blue Cross spokesperson Jami Sowers.
However, the insurer’s online directory includes a disclaimer that information is not guaranteed to be accurate, and that patients should call customer service for the most up-to-date information.
Vulnerable patients most at risk
Not having accurate information about health care providers can also pose a burden for vulnerable populations.
Navigate NC, a patient advocacy agency based in Raleigh, primarily works with aging adults who need help navigating the complex health care system.
Older patients often don’t know how to negotiate insurance claims and are too overwhelmed to fight the bills they get, agency director Nancy Ruffner said. “All too often in that overwhelmed state, they’re like, ‘I just paid it. I just can’t deal with it,’” she said.
Older patients often take it at face value when they’re told a provider accepts a certain insurance plan and they don’t know how to verify the information themselves, Ruffner said.
Even medical staff and advocates like Ruffner can get confused by changing or incomplete information.
“I’ve been caught up in that too,” Ruffner said. “You call, you think you’re doing the right thing. The frontline services say, ‘Oh yeah, we take that (insurance), come on in,’ and come to find out they didn’t take my particular plan.”
States have different rules
Insurance companies have run into trouble in other states for having inaccurate directories.
Georgia fined Anthem $5 million earlier this year for providing inaccurate information about which providers were in-network, the Atlanta Journal-Constitution reported. Similarly, the city of San Diego sued three California insurers over inaccurate directories last year.
While some states like Illinois require insurers to maintain online directories and update them more frequently, North Carolina law only requires insurers to update their directories at least once a year and they don’t have to be posted online.
However, the state does provide oversight on whether insurers are providing adequate access to care. Under the state Administrative Code, insurers must review their networks at least once a year to determine whether they’re meeting patient needs.
Insurers must keep the results of their network reviews for at least five years or until the Department of Insurance inspects them, whichever comes later.
Documents from those inspections are shielded from public view by North Carolina general statutes that make certain insurance companies’ documents confidential, said DOI spokesperson Barry Smith.
In some cases, access to care benchmarks set by insurers may be considered a trade secret, according to the DOI Life and Health division which oversees health insurance.
But some insurers, Blue Cross included, post their access to care standards online. They can give patients an idea of how far they should have to travel or how long they should have to wait to get care.
There have been consequences for insurance companies not meeting benchmarks. Last year, North Carolina entered a voluntary settlement with Humana for charging patients out-of-network fees when there weren’t enough available in-network providers, which is a violation of state law.
That violation, among others, was found during a routine inspection according to the settlement. The company had to pay $630,000 to the state and nearly $230,000 to patients and write a corrective action plan.
This story was originally published August 4, 2022 at 12:13 PM.
