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Advocates find problems with lists of health exchange's OB-GYNs

Advocates find problems with lists of health exchange's OB-GYNs
Carolyn Quattrocki, executive director of the Exchange, pictured in 2013. (Algerina Perna / Baltimore Sun)

For the second time in a year, consumer advocates have found that the specialists listed as available to those who bought health insurance on the state exchange aren't all that available.

When the advocates tried to call the obstetrician-gynecologists in the online directory of insurers' in-network providers, they found the list so outdated that only about 22 percent of the 1,493 practitioners were accepting new patients, performed well-patient visits and had appointments available within four weeks.

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More than a third of OB-GYNs weren't available at all because they had left the networks, retired or were dead — such as Nikita Levy, the former Johns Hopkins gynecologist who killed himself in 2013 after police opened an investigation into allegations he had taken pictures and videos of his patients during pelvic exams.

One phone number led to a tractor-trailer supply store, the Maryland Women's Coalition for Health Care Reform found. Another line was for a private residence.

"We felt there was a problem with the provider directories and there was a broad impact on all consumers," said Leni Preston, who chairs the coalition.

"But why is it that advocates with small resources are having to do what the carriers should be doing, making these 'secret shopper' calls and making sure the lists are up to date?"

Preston said the group was following up on a survey released in January by the Mental Health Association of Maryland, a coalition member. The association found only 14 percent of the 1,154 psychiatrists listed in exchange directories were accepting new patients and available for appointments within 45 days.

The advocates said the outdated lists can lead people inadvertently to go outside their insurers' networks for care.

That happened recently in California, where consumers were charged for using non-network doctors. State regulators fined two insurance companies for network errors; the companies reimbursed the consumers and said they've been working to ensure the accuracy of the lists.

Such problems have been widespread. Federal regulators issued a rule in February that requires insurers on the federal exchange to update provider directories at least monthly.

The National Association of Insurance Commissioners has recommended that insurers on state exchanges also update them monthly.

In Maryland, insurers are supposed to update directories every 15 days, though coalition officials said the OB-GYN panel didn't appear to have been changed in the months it took to conduct the study.

The advocates, exchange officials and insurers all acknowledge the challenges in keeping directories up to date, and CareFirst BlueCross BlueShield, the state's dominant insurer, said it can't handle the task alone.

"Directories cannot approach 100 percent accuracy unless providers take responsibility for notifying carriers when relevant information changes," CareFirst said in a statement. "No matter what insurance carriers do, the industry-wide challenge will persist until provider behavior changes."

The insurer requires its providers to verify and update their information at least twice a year. CareFirst officials have sent letters, postcards, email and made phone calls to encourage participation, the company said, but only a quarter have responded.

Dr. Laurence Polsky, the Calvert County health officer, said insurers' directories have been a problem since before launch of the health exchange in 2014. Polsky, a practicing gynecologist, said he has always kept tabs on the practicing OB-GYNs because there is a shortage in Southern Maryland.

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When doctors retire or move, he said, they don't think to call all the insurers. But he said the insurers should be responsible for the providers they include in their networks.

There are other problems, Polsky said. Carriers will say, for example, that a doctor is only 20 miles away — but in reality works on the other side of the Chesapeake Bay.

That's "not a problem," he said, "if you have a helicopter."

The directories for all sorts of doctors are filled will errors and are often inadequate to help consumers, or doctors trying to refer them to specialists, Polsky said. He hopes the exchange addresses the issue before the next open enrollment.

"People could sign up for a plan thinking there are doctors available," Polsky said. "Only when they call for an appointment will they realize there isn't anyone taking new patients, and then they're trapped for 11 or 12 months until the next open enrollment."

He suggested insurers join together and call all the providers before open enrollment every year, or seek a computer program that can identify active primary care and specialists by their billing activity, and even flag doctors who bill for new patients.

Insurers already have that information because they pay the bills, said Gene Ransom, executive director of MedChi, the state's medical society.

"They're in the best position" to know which doctors are taking new patients, he said. If so many are not, he said, the insurance networks are not adequate to meet consumer needs.

"That's the real issue," Ransom said. "There aren't enough rules around adequate networks."

Maryland health exchange officials say they are working on that.

To address the errors in the directories, officials plan to adopt a recommendation from a work group formed after the survey of the psychiatrist list revealed problems, said Carolyn Quattrocki, executive director of the exchange.

That mirrors action taken by the District of Columbia exchange to allow consumers to report inaccuracies, which are passed on to carriers.

The exchange also plans to publicize a state law that allows consumers on and off the exchange to use out-of-network doctors when there is no in-network option without a financial penalty.

Quattrocki also said the exchange board will begin considering other requirements for insurers ahead of the 2017 open enrollment period to further address network accuracy and adequacy. The requirements will help ensure that consumers can access care without unreasonable delay or travel, she said.

They might require insurers to audit themselves to determine a baseline of how accurate the directories are, because "the truth is we don't have great data on the scope of the problem, where it's worse and in what specialties," she said.

"We're obviously concerned about this and have been working with all parties who need to be involved and are fashioning some effective solutions," Quattrocki said. "Carriers provide the data that go into our directory. But we obviously want to do what we can to move some solutions forward."

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