Cypress neurologist Navin Kesari, MD, didn’t expect to be removed from Blue Cross and Blue Shield of Texas’ (BCBSTX’s) network directory.
He’d had no prior issues with the health plan’s directory, and no reason to believe that would change.
That is, until he began receiving patient portal messages claiming that BCBSTX had issued an email stating he was no longer in network.
Dr. Kesari’s billing manager, who handles the practice’s credentialing, confirmed that nothing had lapsed; all requirements had been met to maintain network status. Nor had the practice received communication prior to being removed from the BCBSTX directory, which has since been corrected.
“We kept looking into it and kept looking into it – ultimately, we escalated it to [the Texas Medical Association] and got it up to a supervisor above the person we had been contacting,” Dr. Kesari said. “But at the end of the day it was, ‘We have no idea why this happened.’”
With even BCBSTX unable to identify the error that led to Dr. Kesari’s disappearance from the directory, neither party can say the problem was related to requirements posed by the No Surprises Act. Since the federal law took effect in January 2022, implementation and enforcement of certain provisions have been slow to nonexistent, leaving the directory requirements – which are crucial to assessing network adequacy and patient protections – largely to the wayside.
But Dr. Kesari’s mystery – and consequences for physicians and patients – illustrate just why lawmakers included directories in the act. (See “
Seeking Balance.")
As U.S. Rep. Lloyd Doggett (D-Texas), an early champion of such patient protections from surprise medical bills, recently put it in a September U.S. House Ways and Means Committee hearing addressing the act’s flawed implementation: “I was inspired by [constituent] stories – in my case, a Texas woman who did all the checking to be sure she was in network,” he said. “Then some instrument was used, unknown to her, in the course of surgery, and she got a huge bill for that instrument, which was out of network.”
With many patients finding in-network care by searching their health plan’s directory, Dr. Kesari says any errors or gaps also can cost his practice valuable opportunities – and cause unnecessary strife for patients, too.
“I’ve gotten so many referrals [through health plan directories]. How did you hear about us? Oh, we saw your information online from our insurance provider,” he said. “So, if any of that information is incorrect or out of date, then [patients] get confused and upset.”
In that way, the directory’s role in accurately representing a health plan is key in protecting patients, according to Kelly Walla, TMA’s general counsel.
“If a health plan is offering a product, they should be representing it accurately,” she told Texas Medicine. “The directory serves multiple purposes, and one of those purposes is to aid in assessing network adequacy. It’s also for the consumer to be able to assess whether they want to purchase that plan, so if that information is inaccurate, that’s problematic.”
Uneven burden
This was the line of reasoning TMA used to successfully advocate for strong directory reforms in Texas in 2019 for state-regulated health plans.
“The legislation that we’ve passed at the state level has put the onus on the health plan to keep up with their provider directories, because they’re the ones that create the network,” said TMA’s chief lobbyist, Vice President of Public Affairs Clayton Stewart.
Regulators can use an accurate directory as a means to assess network adequacy, a major priority of TMA’s. Medicine in Texas saw a win in that area this regular legislative session, with the unanimous passage of House Bill 3359 putting additional network adequacy measures into statute and strengthening their enforcement by the Texas Department of Insurance. (See “
Closing the Gap.”)
But on the national level, despite the No Surprise Act’s requirements, physicians have yet to see health plans take the initiative to improve their directories, leaving holes in patient coverage. Besides inaccurate addresses or specialties, TMA also has fielded concerns from physicians that they are misrepresented in directories when their contract provides for participation in multiple products but they don’t provide certain services under all those products.
Though the writing of the law directs health plans to initiate verification, no final rule has been released, leaving plans to “implement the requirements using a good faith, reasonable interpretation of the statute,” 2021 interim final rules state.
Under the federal No Surprises Act, health plans must:
- At least every 90 days, verify and update directories;
- Establish procedures for removing physicians for whom plans are unable to verify information;
- Update information within two business days of receiving any changes from a physician;
- Respond to requests regarding network status of the physician within one business day and retain communication for two years;
- Retain a website directory with contracted physicians and directory information (name, address, specialty, telephone number, digital contact information); and
- Post information on balance billing protections including, if provided under state law, the amount physicians/facilities may charge, and appropriate federal and state agency contacts to report violations.
Similarly, physicians must have a plan in place to ensure timely provision of directory information to a health insurer, and at minimum, submit to the plan:
- When beginning a network agreement with a plan with respect to certain coverage;
- When the physician terminates an agreement;
- When there are any material changes to the content of directory information; or
- At any other time (including upon the request of the plan or issuer) determined appropriate by the provider, health care facility, or the secretary of the U.S. Department of Health and Human Services.
Authors of a March study in the Journal of the American Medical Association (JAMA) expressed concern that, as they stand, the guidelines risk adding to physician practices’ administrative burden by requiring them “to send directory updates to insurers via disparate technologies, schedules, and formats” at a collective annual cost of $2.76 billion.
With some physicians contracting with seven or more health plans, according to TMA Vice President of Medical Economics Robert Bennett, the hassle factor is unignorable.
Mr. Bennett says this potential burden is significant, but at least some of it is necessary to provide accurate directories for patients as well as hold health plans accountable for inadequate networks.
“Otherwise, it’s the plans just assuming and renewing, and we can’t trust that process,” he said.
For instance, some Texas physicians have struggled to update their information because of unresponsive health plans. Put simply by Bill Gilmer, MD, a member of TMA’s Council on Constitution and Bylaws, when it comes to directory verification, “That is not happening to me. I am not getting those requests.”
“I’m listed as a psychiatrist,” continued Dr. Gilmer, a neurologist. “No, I’m not a psychiatrist. And no one’s asked me.”
Dr. Gilmer voiced such concerns at “No Surprises Act – What’s the Impact on Your Practice?” a CME presentation by Mr. Bennett at TMA’s Business of Medicine Conference in October. Mr. Bennett wasn’t surprised by the response, given enforcement challenges.
In fact, the JAMA study found 81% of physician entries were inconsistent across five large national health plans’ directory data. The most common inconsistencies were practice location addresses and physician specialties.
Study authors echo concerns expressed by TMA: that health plans’ failure to comply with directory requirements hurts patients, consumers, and physicians.
“Beyond surprise billing, inaccurate physician directories can lead to delays in care due to difficulty finding the correct physician, challenges in regulators assessing health insurer network adequacy, and misrepresentation of network depth and breadth as consumers select health plans,” they wrote.
No enforcement, no movement
As written in the No Surprises Act, if a patient relies on erroneous directory information, the plan cannot impose a cost-sharing amount greater than in-network rates, and any cost must count toward the patient’s in-network, out-of-pocket maximum and in-network deductible. The plan also is “expected” to pay incorrectly listed physicians their previously contracted rate.
However, it’s unclear if a purely monetary consequence will be enough to spur action from health plans.
For his part, Dr. Kesari would be happy to cooperate with health plans if doing so gave his patients reliable information. Physician verification doesn’t have to be a hassle, he says.
“In an ideal world, I would say it’s an email,” he said. “Here’s a link, log in, make sure all the information is correct. In theory, you should be able to look at all the information, locations, addresses, fax numbers, etc., click ‘Yes, this is all correct,’ and then it stays that way.”
Such a process could be delegated to practice staff – assuming a physician has such staff to lean on.
“I’m a one-person office,” Dr. Gilmer said. “If it comes in a fax, it will go to the front desk. If it comes to me in my personal email, I’ll answer it. [The burden] varies on size of practice, and I don’t know how health plans are going to consider that.”
TMA continues to closely monitor rulemaking related to the No Surprises Act.