90% of compliance data submitted to DMHC from the California health plans was inaccurate for 2015.
The California Department of Health Care released a report confirming that several health plans may have had inaccurate provider directories for their member to search through. The Timely Access Report year 2015 reviewed several different measurements to determine if health plan members could obtain timely access to health care services. The report noted that 13 health plans listed Primary Care Physicians who were not in the health plan’s provider network.
Health Plans Inflate Number of Doctors In-Network
Health plans UnitedHealthcare, Cigna, Anthem Blue Cross, Blue Shield, and Aetna had the highest number of providers listed in the compliance reporting to DMHC but were not listed on the plans provider roster. What is unclear from the DMHC Timely Access Report is how closely the Provider Roster submitted to DMHC mirrors the online search tools used by consumers to determine if a doctor is in-network.
Primary Care Physicians listed in DMHC compliance report but not listed on the health plans roster of doctors.
Much of the blame for the inaccurate Provider Roster was placed on one vendor, The Health Industry Collaboration Effort, Inc., who compiled the DMHC compliance reports for 24 of the health plans. However, 36 out of 40 health plans failed to submit accurate Timely Access compliance data for 2015 according to the report.
The DMHC cannot determine (or report to the public) how many health plans did (or did not) comply with the appointment availability requirements, due to the failure by nearly every plan within the industry to submit accurate compliance data. This undermines the purpose of the Timely Access laws and regulations, which require an annual review of health plan networks for the express purpose of determining whether consumers can see their doctors to obtain medically necessary services on a timely basis.
The data submitted by health plans for 2015 contains so many errors that it is virtually impossible to draw conclusions regarding individual health plan compliance and performance across the industry.
Faulty Data Provided By One Vendor
DMHC indicated that they attempted to ascertain how The Health Industry Collaboration Effort, Inc. (ICE) could have provided so much inaccurate information. The conclusion by DMHC was that the health plans failed to validate the data ICE collected and provided on the compliance reports.
Percentage of Primary Care Physicians listed in DMHC compliance report by not on health plan roster.
Not only were the in-network Primary Care Physicians inflated by the health plans, so were the specialists. Aetna Health of California reported that their network contained more than 30,000 cardiologists, dermatologists and allergists. DMHC found that Aetna reported the same cardiologists, in the same group, in the same county, was replicated more than 160 times. This error on Aetna’s part rippled through the whole DMHC analysis.
As a result, Aetna Health of California, Inc. greatly overinflated its reported specialist network. The magnitude of the error was large enough to distort all health plan data and, until discovered by the DMHC, resulted in inaccurate analysis regarding health plan outliers. Therefore, this error by Aetna Health of California, Inc. alone affected the DMHC’s overall ability to evaluate and compare plans.
Some health plans failed to provide any provider data in certain specialist categories.
L.A. Care Health Plan also confirmed that it did not provide data regarding compliance in the areas of child psychiatry, physical therapy, and mammography, due to the plan’s failure to provide a complete provider roster to its vendor. This prevented the DMHC from analyzing the plan’s compliance with the Timely Access laws and/or comparing the plan’s performance across the industry.
DMHC pretty much admitted the whole Timely Access Report for 2015 was a failure.
Ninety percent of 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.
There may be some help for consumers with new regulations forcing health plans to provide more accurate and meaningful provider search results. The Uniform Provider Directory Standards goes into effect in 2018. DMHC issued a Public Notice of draft provider directory standards. While most of the health plans seem to already have most of the information listed under the new directory standards, a large problem is just the variability of the search engine between health plans. (See: Health Plan Directories Suck). Each search engine is different on how it takes the user through filtering for specific providers. And just because the provider directory conforms to all the new standards, that still doesn’t mean that doctors shown really aren’t in-network or might be listed multiple times to inflate the provider results.
Timely Access Report Measurement Year 2015
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Uniform Provider Directory Standards
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