Insurance provider lists are full of lies

The Pediatric Insider

© 2014 Roy Benaroch, MD

A goal that’s become The Major Talking Point about health care reform is to get more people into health insurance plans. There are XX million uninsured, they say, and this new scheme will help provide insurance to XX people. But just having insurance won’t make anyone healthier. Insurance has to allow access to health care providers in a timely manner.

Unfortunately, that isn’t always the case. A study just published in JAMA Dermatology demonstrated that many provider lists for health care plans are outrageously inaccurate, and greatly overstate the number of providers in health networks.

Researchers in California collected the currently-published physician directories for all of the Medicare Advantage plans available in their state. They looked at one specialty, dermatology, finding a total of 4754 total physician listings. About half of these were duplicate entries, with the same physician appearing multiple times in the same directory. They called every single one of the 2591 actual unique providers, and found that only half of those could be reached, were accepting patients in the plan, and could offer an appointment. For one of California’s Medicare Advantage plans, not a single dermatologist was available. Net for all plans, about 25% of the “listed dermatologists” in the plans could actually see you as a patient – and even then, the average wait time was 45 days.

Having health insurance is important, but it’s not the same as having health. Patients need to be able to see doctors; they also need to be able to get prescription drugs or ride an ambulance if necessary. And they need the cash to meet ever-growing deductibles. Cheap health insurance isn’t really very useful if you can’t use it. While this study doesn’t speculate on why the insurance booklets are so inaccurate, it’s obvious that if the insurance companies wanted accurate provider directories, they could make them. After all, in one quick phone call I can find out if a patient’s insurance covers a visit with me. Their computers know. But if you’re a health insurer, it’s better for you to misrepresent and obfuscate and over-state your networks. Their listings say 4754 dermatologists are in-network; but less than 1500 are really available to see you.

The goal of the insurance companies (and government-funded health care coverage bureaucracies) hasn’t changed. They want to spend as little as possible on your health care. Since they can’t exclude pre-existing conditions any more, they’ve come up with new ways to keep your premiums to make big profits. Tiny, limited networks are one trick. They make it very difficult to get an appointment, and care delayed is care they may not end up paying for. Even better for them: sometimes people become so frustrated that they see an out-of-network provider, paying with their own cash. You pay—you lose; you pay—they win.

EDIT: After I wrote this, a study was published looking at Medicaid — and found that about half of the providers on the lists were retired, dead, or not seeing Medicaid patients. Half is better than 25%, but both figures are terrible. Both private and public health insurers are way overstating their provider numbers.

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One Comment on “Insurance provider lists are full of lies”

  1. Thanks for writing about this. It is too difficult to be an informed consumer when trying to pick an insurance plan. It isn’t just provider lists that are problematic. Many people look at the cost comparisons of monthly payment, deductible, co pay, etc, but forget to look at the formulary coverage. I try to train my patients to do just that if they are on a regular medicine to see what their real cost will be. For many of my patients (and my own family) even when we looked at the formulary for a new plan, we could see only the 2014 version while shopping for the 2015 plan. For many of my patients Concerta and its generics were on the 2014 plans, but are removed for 2015. (I’m sure there are other drugs as well, but this one in particular affects many kids.) There was no warning. Now they either must change to another medicine (and I don’t think there is another drug in that class that compares favorably) or they must pay cash. It doesn’t even apply to their deductible, just cold hard cash as if they are uninsured. This is going to be hard on many families (and schools) during the transition while many ADHD kids try to find a new medicine they do well on).


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