Health insurance policies are required by law, but they are often flawed

If you have health insurance, chances are you’ve been frustrated at some point trying to find a doctor or specialist in your plan’s network.

You find several providers in your plan list, and you call them. All of them. But the number is wrong. Or the doctor has moved or retired or is not accepting new patients. Or the next available period is three months. Or the provider is not in your network.

Even federal and state laws that require accurate health care information, can contain errors and are often out of date.

Poor documentation doesn’t just hinder our ability to care. They also show that health insurers aren’t meeting requirements to provide timely care — even when they tell regulators they are.

Worse, patients who rely on inaccurate information can face higher bills from doctors or hospitals that are outside their network.

In 2016, California passed the law improving the accuracy of donor guides. The government is trying to deal with long-standing problems, which shows embarrassing in 2014, when Covered California, the state’s insurance marketplace created after passage of the Affordable Care Act, was forced to retract its flawed manual within its first year.

Also in 2016, the federal Centers for Medicare & Medicaid Services requested very accurate for Medicare Advantage health plans and plans sold in the federal ACA marketplace. A federal agency No Surprises Actwhich started working this year, continues similar rules for employer-based and private health plans.

The No Surprises Act states that patients who rely on information in their provider records and unknowingly end up seeing doctors outside their network will not have to pay more than they would have paid for an in-network provider.

Unfortunately, poor documentation continues to plague the health care system.

A study published in June in the Journal of Health Politics, Policy and Law analyzed data from the California Department of Managed Health Care on directory accuracy and timely access to care. It found that, if it’s good, consumers can get an appointment with an urgent problem with only 54% of the doctors listed in the book. At worst: 28%. In the usual care selection, the best cases were 64% and the worst 35%.

The main point, the authors wrote, “even the progressive and pro-consumer laws and regulations have failed to provide adequate protection for consumers.”

Few know this better than Dan O’Neill. San Francisco’s health director called the doctors listed on his health plan, through a large national network, and couldn’t get an appointment. No one she spoke to could tell her if UCSF Health, one of the city’s health services, was in her network.

O’Neill said: “I spent about a week trying to get it resolved and then I gave up and paid $75 to go to the hospital because it was the only way I could do it. “Now I live seven or eight minutes from the main buildings of UCSF, and, to this day, I don’t know if they’re online or not, which is crazy because I do this professionally.”

Consumer health advocates say insurers aren’t tracking site accuracy.

“We have health plans with millions of people enrolled and hundreds of millions more in the reserves,” says Beth Capell, an advocate for Health Access California. “These people have the resources to do this if they think it’s necessary.”

Industry researchers and academics say it’s more complicated than that.

Health plans interact with hundreds of thousands of providers and must pester them to send updates. Do they still have the same behavior? At the same address? Accepting new patients?

For doctors and other clinicians, responding to such research — sometimes from multiple health systems — is not high on their to-do list. Insurers often offer multiple health plans, each with different coverage groups, which are not always known.

The law gives insurers an opportunity to hold providers accountable, and business has begun to revolve around collecting provider updates through a central portal and selling the information to health plans. Yet health plans and providers often have outdated systems that don’t connect.

A major improvement in health care policy will require “a lot more communication and coordination,” says Simon Haeder of Texas A&M University’s School of Public Health, a co-author of the study on directory accuracy and timeliness.

Until that happens, you have to take care of yourself. Use your health care directory as your first stop or to see if a doctor recommended by a friend is in your network.

Remember the rules that say you can’t be charged out-of-network rates if the doctor you go to is listed on your health plan? You have to prove that it was. So take a picture of the book that shows the donor’s name – and save it.

Call your doctor’s office for a second evaluation. Take notes. Find the name of the person you spoke to. If there are any inconsistencies or if you find any errors, report them to your health plan.

KHN (Kaiser Health News) is a national newsroom that produces in-depth health journalism.