Improving Patient Access to In-Network Providers

It’s plain that COVID-19 has dramatically accelerated the much-anticipated implementation of telemedicine. As the pandemic spread, the Centers for Medicare & Medicaid Services expanded coverage of telemedicine, and private insurers followed suit. Providers scrambled to put their long-range telehealth plans into everyday practice, and within a matter of weeks there was an estimated ten-fold increase in telehealth consultations.

The rush to make telehealth available now enters a new phase, in which providers and insurers must deliver what healthcare consumers want: seamless, accurate access to in-network providers.

Telehealth expansion exposes demand for access to in-network providers.

Recent industry research shows that patients aren’t confident that their health plans cover telehealth services, and they are unlikely to schedule a virtual visit without reassurance that their chosen provider is in-network.

• According to a DocASAP telehealth survey, 45% of healthcare consumers said their insurer’s telehealth coverage influenced their decision to schedule a virtual appointment
• However, only 28% of consumers reported knowing whether their insurance company covered telehealth appointments pre-COVID.
• Consumers already search for providers via portals and apps associated with their health plan. DocASAP consumer trend research reveals that 43% of consumers search for available providers through their health plan’s member portal or app.

However, the accuracy of provider listings and online scheduling needs to improve.

• Research reported in The Hill reveals that 12% of privately insured adults noted errors in fundamental directory information, including out-of-date provider contact details, and inaccurate advice on whether the provider is covered by the patient’s insurance.
• The American Journal of Managed Care reported that in a January 2018 survey by the American Medical Association (AMA) and LexisNexis Risk Solutions, 52% of physicians said their patients encounter coverage issues at least once a month due to inaccurate directories.

Patients should be able to easily identify – and schedule appointments with – providers within their coverage network

Poor provider matching and inaccurate provider directories can lead consumers to choose providers who are not in-network. The consequences include surprise bills and plummeting patient satisfaction. 

Behavioral health is particularly prone to out-of-network error, in part because many psychiatrists don’t accept commercial insurance. According to a study in Health Affairs, mental health services are “up to six times more likely than general medical services to be delivered by an out-of-network provider.” The study surveyed privately insured patients who received specialty mental health care. Some 44% of these used a mental health provider directory, and 53% encountered directory inaccuracies. These patients were more likely to be treated by an out-of-network provider, and four times more likely to get a surprise bill. 

The Healthcare Cost Institute studied out-of-network billing, and found that Emergency Medicine and Pathology were two specialties that rank high in out-of-network billing. Indeed, the study reported that “36% of pathologists billing out of network for inpatient visits and 20% of pathologists billing out of network for outpatient visits did so more than 90% of the time.”

For providers and patients, it is frustrating – and expensive – to stay current with listings.

Inaccurate health plan information in provider directories creates a poor patient experience that can lead to surpise medical bills. A Kaiser Family Foundation investigation found that patients are often the last to know when their long-time providers leave their health plan’s network. One patient shared that they felt “sickened” when they learned too late that access to their provider was no longer covered under their insurance – landing them an unexpected $849 bill during a pandemic.

Meanwhile, providers must work hard to keep their information up to date for dozens of health plans. A survey by CAQH found that inaccurate provider directories costs physician practices some $2.76 billion annually.

Clearly the question of accuracy in listings needs to be addressed. The Health Affairs study concludes that stronger enforcement of existing laws, and perhaps a federal accuracy standard might be necessary to reduce surprise billing. However, CAQH writes that a single platform for provider search and appointment scheduling can “enable meaningful progress on the provider directory dilemma.”

Next Steps to Enhance Access to In-Network Providers

Payors and providers can help guide patients to the right care, and avoid surprise bills, by offering improved patient navigation tools and more efficient provider data management:

• Empower patients to filter providers by their accepted health plans, in both find-a-doctor tools and online scheduling utilities
• Enable members to search for in-network providers, and schedule appointments directly via their health plan’s portals and apps
• Providers will need to adopt a robust data management solution to update consumer-facing applications with important consumer information such as what insurance a provider accepts, integrated with the convenience of online appoint,ment scheduling 

For more insight on improving telehealth access and boosting patient engagement, download the DocASAP eBook Telehealth: Taking the Pulse of the Healthcare Consumer in the New Normal, and check the section “Strategies for Optimizing Telehealth”