The White House is moving to address two of the most common consumer complaints about the sale of health insurance under the Affordable Care Act: that doctor directories are inaccurate, and that patients are hit with unexpected bills for costs not covered by insurance.
Federal health officials said this week that they would require insurers to update and correct “provider directories” at least once a month, with financial penalties for insurers that failed to do so. In addition, they hope to provide an “out-of-pocket cost calculator” to estimate the total annual cost under a given health insurance plan. The calculator would take account of premiums, subsidies, co-payments, deductibles and other out-of-pocket costs, as well as a person’s age and medical needs.
Since insurers began selling coverage through public marketplaces 19 months ago, many consumers and doctors have complained that the physician directories are full of inaccuracies. “These directories are almost out of date as soon as they are printed,” said Kevin J. Counihan, the chief executive of the federal insurance marketplace.
Medicare and Medicaid officials have found similar problems in the directories of insurance companies that manage care for beneficiaries of those programs. In December, federal investigators said that more than a third of doctors listed as participating in Medicaid plans could not be found at the locations listed.
The Obama administration recently adopted stricter standards stating that each insurer in the federal marketplace “must publish an up-to-date, accurate and complete provider directory, including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group and any institutional affiliations.”
In addition, Mr. Counihan said, the administration will require insurers to provide physician information in a format that software developers can use to create tools to help consumers find health plans in which their doctors participate. Consumer advocates like Robert M. Krughoff, the president of the Center for the Study of Services, also known as Consumers’ Checkbook, said such tools could be a boon to consumers.
The new standards significantly strengthen an earlier rule, which required insurers to publish directories online and to make paper copies available on request. In the federal exchange, violations are subject to civil penalties of up to $100 a day for each person adversely affected.
Federal officials said that inaccurate provider directories could be a sign of larger problems. If doctors listed in a directory are not available or are not taking new patients, consumers may not have access to covered services, and the insurers may not meet federal standards for “network adequacy,” the officials said. Consumers must often pay extra when they use doctors outside the network of their health plan, so an inaccurate directory could also lead to higher costs for patients.
Moreover, doctors said that they too need accurate directories so they can refer patients to physicians in the network when specialized treatment is required.
“The impact of inaccurate provider directories on consumers can be devastating, especially on those consumers who need to carefully examine networks for specific subspecialists, cancer centers or children’s hospitals,” the American Medical Association told state insurance officials in a recent letter endorsed by dozens of health care provider and patient groups.
But insurers say that the problems might not be easy to fix, and that doctors are partly to blame for the directory errors. Insurers “are unable to guarantee the accuracy of the provider’s status” in a directory because doctors often “stop accepting particular health plans’ members off and on throughout the year and fail to notify the plan in a timely manner,” America’s Health Insurance Plans, the chief lobby for the industry, said in a letter to the Obama administration.
In its online doctor directory, Blue Cross and Blue Shield of Texas says that it makes every effort to provide correct information, but that it “cannot be responsible for omissions or errors in the provider details.” Aetna says that data in its directory is “subject to change at any time.” UnitedHealth tells Medicare beneficiaries, “A doctor listed in the directory when you enroll in a plan may not be available when your benefits become effective.”
The problems that consumers face with unexpected costs may result, in part, from the way plans are listed on HealthCare.gov, the website for the federal marketplace. More than 8.5 million people are in private health plans selected through the site, and the plans are listed in order of their premiums, from lowest to highest.
This encourages consumers to focus on premiums rather than total costs, said Mr. Krughoff, the Consumers’ Checkbook president, and they often spend hundreds or thousands of dollars more than they need to.
Mr. Krughoff’s group has been publishing a guide to health plans for federal employees for more than 30 years, and a version of its online tool for comparing health plans is available on the website of the federal marketplace in Illinois. “It’s been a great tool,” said Jose M. Muñoz, a spokesman for Get Covered Illinois, the state agency that promotes enrollment.
The tool can perform searches tailored to a person’s needs and priorities. It asks consumers to describe their health status, offering five levels from excellent to poor, and to list “expected medical procedures” like childbirth, knee replacement or prostate removal. It also provides an estimate of total yearly costs for the user.
Federal officials said that they might link HealthCare.gov to an out-of-pocket cost calculator later this year, and that they hoped to make such comparisons a standard part of the shopping experience at the site in later years.
“We know that we have work to do to make it easier for consumers to find plans that meet their needs,” said Lori Lodes, a spokeswoman at the Centers for Medicare and Medicaid Services, which runs the federal marketplace serving more than 30 states.
A few state-run exchanges are developing similar tools. Peter Nichol, the information technology director for the state insurance exchange in Connecticut, said it would add a “cost calculator” to its website this summer.
The Obama administration is also taking steps to increase the accuracy of doctor directories in Medicare. About 30 percent of the 55 million beneficiaries are in private Medicare Advantage plans that typically use networks of doctors to care for patients.
The Medicare agency said it had received complaints about insurance company directories that included doctors who “have retired from practice, have moved locations or are deceased.” New federal rules will require insurers to update their Medicare directories each month, “with specific notations to highlight those providers who are closed or not accepting new patients.”