DMHC Criticizes Anthem, Blue Shield On Directories Again
A survey of Anthem Blue Cross and Blue Shield of California released late last month by the Department of Managed Health Care (DMHC) concluded that neither made substantial progress in providing updated provider directories to enrollees who purchased coverage through the Covered California health insurance exchange.
In 2014, the DMHC received numerous complaints from Covered California enrollees saying that the providers they selected were not actually participating in the plans they had purchased through the insurance exchange. In Anthem's case, more than one in eight providers were rejecting enrollees' Covered California plans, while nearly 9% of Blue Shield providers were rejecting coverage and more than 18% were not practicing in the locations listed in the directory.
The complaints led to fines of $350,000 against Blue Shield and $250,000 against Anthem. Both carriers agreed to take corrective actions.
But according to the non-routine surveys undertaken by the agency that occurred in late 2015 and early 2016, only 56% of 3,063 providers reached by telephone confirmed that they were Anthem Blue Cross network participants. Nearly a quarter said they no longer practiced at the location listed in the directory. Another 8.9% said they did not participate in the network; 5.7% said the phone number in the provider directory was incorrect; and 4.6% said they were unsure if they provided services through the health plans/products discussed in the directory.
Blue Shield, which had 2,516 of its providers surveyed in late 2015, fared little better. Just 58.1% of providers said the information in its member directory was correct. Another 26.2% said they no longer practiced at the location listed. Another 7.7% said the were unsure if they provided the services through the plans/products as listed. And 3.2% said the phone number listed in the directory was incorrect.
The DMHC conceded that many providers could not be contacted directly – nearly 40% in Anthem's case and 34% in Blue Shield's. “This significant percent of unanswered provider contacts underscores the challenges health plans face in maintaining accurate provider directories,” the agency said in both surveys.
Anthem issued a statement saying in part that “since the follow up study was conducted, Anthem has made thousands of updates to the database and now makes updates on a weekly basis. Anthem has nearly two-dozen associates dedicated to maintaining the directory, and will continue to work with doctors to update their information so we can provide the best possible experience for our customers.”
Blue Shield also issued a statement declaring that “while we disagreed with some of the survey methodology that yielded these results, we continue working with the DMHC and stakeholders to improve provider directory accuracy and the experience for our members.”
The DMHC and both health plans said that the upcoming implementation of a new state law, SB 137, will likely improve matters. The bill requires health plans to make quarterly updates of printed directories and weekly updates of online directories by July 2017. Insurers may delay payments to providers that do not promptly update their contact information.
“Access to care often starts with the provider directory, which is why its accuracy is so important,” said DMHC Director Shelley Rouillard. “While I am disappointed the corrective actions implemented by the plans to date have not resulted in more accurate provider directories, we expect measurable improvement with the full implementation of Senate Bill 137. This legislation provides a new comprehensive framework for the regulation of provider directories and adds significant
accountability for health plans and providers.”
In another action, the DMHC withdrew an order against Blue Shield to maintain coverage for 21 members who had been referred from CenCal, the Medi-Cal insurer for Santa Barbara and San Luis Obispo Counties. According to the order, an unnamed third party believed to be CenCal agreed to continue coverage for the enrollees and cease payments to Blue Shield on Aug. 31.
Blue Shield spokesperson Steve Shivinsky previously confirmed that CenCal would withdraw its enrollees from Blue Shield and that “CenCal will take all necessary action to ensure the continuity of care for all affected members.” CenCal had lodged its enrollees – many of whom were seriously ill and awaiting organ transplants – within Blue Shield as part of the California Department of Health Care Services' Health Insurance Premium Program. But Shivinsky said that CenCal was terminating that program as of the end of this month.
