TMA: Don't Make Docs Pay For Inaccurate Plan Directories

Calling it either "an enormously unfortunate oversight" or "a government grab at discount health care services," TMA is vehemently opposing a new federal policy regarding physician participation in the Affordable Care Act exchange marketplace health plans. The policy is one of the "smooth transition" policies the U.S. Department of Health and Human Services (HHS) recommended in an interim final rule published Dec. 17, 2013.

At issue are the notoriously inaccurate provider directories that health plans publish. In the interim final rule, HHS acknowledged that patients choosing a marketplace plan very well could be misled if they rely on the often-outdated directories the plans publish. Nonetheless, that interim final rule "strongly encourages" health plans to treat any out-of-network physician as in-network if the plan incorrectly lists that physician in its directory.

"In other words," TMA wrote in a strongly worded letter to HHS officials, "a physician's out-of-network status may change, without the physician's knowledge or consent, based solely on a [plan's] failure to maintain an accurate provider directory." 

Effectively, the policy would require physicians to abide by terms of a contract they have not agreed to and actually may have rejected or terminated. "This suggests that the traditional contractual relationship between a health plan and an in-network physician be trumped by a rule of convenience," TMA wrote.

To emphasize the importance of its concern, TMA shared the results of its 2012 Survey of Physicians, which found that 62 percent of physicians had detected cases in which they were listed as participating in networks when in fact they were not. Medical and surgical specialists reported the bad listings most frequently.

To protect both patients who rely on the inaccurate directories and the physicians who are erroneously listed, TMA suggested several additions to the interim final rule:   

  1. Health plans "shall fully pay" the incorrectly listed physician and calculate the patient's financial responsibility for services provided to patients who buy a marketplace exchange plan based on the out-of-network physician's billed charge.
  2. For patients in "special circumstances," in which the physician believes discontinuing care could cause harm, the physician may ask that he or she continue to provide care to the patient. In those cases, the plan will "fully pay" the physician based on the out-of-network physician's billed charge. The patient would be responsible for no more than he or she would have paid if the physician actually was in-network.   

"TMA strongly opposes the financing of [marketplace] coverage on the backs of physicians," the association wrote. "Only [the marketplace plans] have the access, ability, and obligation to ensure that provider directories are accurate and up-to-date, and [they] must be held accountable for such misrepresentations." 


Action, Jan. 3, 2014


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