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Review Finds Errors in Most CA Provider Directories

News  |  By Doug Desjardins  
   February 19, 2017

The California Department of Managed Health Care found 36 out of 40 insurers' reports for 2015 contained data inaccuracies significant enough to render them unusable.

This story originally appeared in California Healthfax.

A state review of provider directories and compliance reports supplied by insurers found most insurers had conflicting information on the number of physicians in their provider networks.

The California Department of Managed Health Care (DMHC) issued a report that found that 36 out of 40 Timely Access Compliance Reports submitted by insurers for 2015 contained "significant data inaccuracies" to the degree that they were not usable.

"Ninety percent of the 2015 Timely Access Compliance Reports submitted to the DMHC contained one or more significant data inaccuracies, making it virtually impossible for the DMHC to measure individual health plan compliance and compare plans across the industry," the report stated.

As part of its review, the DMHC compared the identity of primary care physicians (PCP) in each insurer's Compliance Reports and Provider Rosters, with one providing a list of physicians available to members during the year and the other a year-end summary of providers.

The reports listed a significant percentage of PCPs who were not actually part of the health plan's own network of providers, based on the information provided by the plan through its Provider Roster, according to the review.

Provider Directory Data Accuracy in CA Law's Crosshairs

Care 1st Health Plan had the highest percentage of physicians listed in the compliance report but not listed in the plan's provider roster, at 56%, the DMHC report stated. UnitedHealthcare of California had a rate of 45% , and 43% of physicians listed on Health Net's compliance report were not on the plan's provider roster.

Blue Shield of California had the lowest percentage at 22%. Others with low percentages including Cigna (36%), Anthem Blue Cross (36%), and Aetna (29%).

"Health plans that failed to follow the mandatory DMHC methodology or submitted inaccurate or erroneous data … violated California's health plan law, known as the Knox-Keene Act," and could face fines, the report stated.

"The DMHC's Office of Enforcement will be investigating these plans for possible disciplinary action."

Vendor Errors
The report attributed some errors to "a failure by health plans to follow mandatory DMHC methodology;" other errors were attributed to one source.

A single vendor hired by numerous health plans to gather data and prepare compliance reports may have caused significant errors, the report stated. Twenty-two health plans that used this vendor submitted deficient compliance reports.

Insurers declined to comment on the reports and referred inquiries to the California Association of Health Plans (CAHP).

21 Medicare Health Plans Warned To Fix Provider Directory Errors

Timely access to care is difficult to measure, but some health plans "have work to do" in providing better data, CAHP CEO Charles Bacchi said.

"Health plans are committed to providing timely access to healthcare and we believe that we provide that successfully," said Bacchi. "Unfortunately, timely access to care is difficult to measure in every doctor's office across the state.

"Clearly, this report demonstrates that we have work to do to improve our survey responses."

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