Jackie first noticed she had a bulls-eye rash early this summer.
Over the course of a few weeks, the rash grew from about a half inch to two inches in diameter and became lumpy. Concerned, and at the advice of a friend who was a nurse, Jackie called her primary-care physician. The doctor was assigned to her by her San Jose-area health insurance plan, and this would have been her first visit to his office.
When she called, however, his office told Jackie that her doctor was a specialist, not a primary care physician. She would need to see someone else, they informed her. Jackie, who requested that her last name be omitted because she is concerned insurers could retaliate against her for speaking out, called her insurance company, Anthem Blue Cross, and asked for help finding another doctor.
Armed with a list from Anthem Blue Cross, Jackie tried again, calling a doctor in Anthem’s directory. But, she recounted, “the receptionist said, ‘He’s not taking anybody and we’ve been trying to get off the list for three years.’”
“The directory was not up-to-date,” Jackie said, “at least for the doctors I called.” A nonprofit professional with advanced degrees, it was several weeks before she found a primary care doctor who would accept her insurance.
Under a 2015 state law, insurance companies in California are supposed to update their doctor lists weekly and provide easily searchable directories on their websites. This is meant to ensure that patients seeking medical care or shopping for insurance plans have accurate information.
California Health Report’s research—as well as stories from patients and advocates—shows that two years into the new law, doctor directories are still frequently inaccurate and unreliable, jeopardizing health care access for Californians.
“The question is, ‘is the information accessible and accurate enough so it doesn’t end up delaying care?’” said Mike Odeh, director of health policy for the California advocacy group Children Now. “If you keep calling a bunch of providers and they’re not available, does that end up meaning you don’t get care?”
A California Health Report investigation in June 2014 found that doctor directories given to low-income patients across California were highly inaccurate. At the time, more than half of the primary-care doctors in provider directories given to low-income patients in three counties in Northern, Central and Southern California were not accepting new patients with Medi-Cal, the state’s low-income health plan, or could not be reached by telephone.
At one plan in Butte County, more than 95 percent of the doctors listed in the printed directory were either unavailable to new patients or could not be reached. Even in the most accurate directory, from a plan in Fresno County, reporters were able to confirm that a doctor would see a new patient at only six out of every 10 offices listed.
The investigation spurred a state audit, which backed up the reporting and found that the state agency that oversees Medi-Cal had failed to ensure that those patients had adequate access to doctors. The California legislature stepped in, and in October 2015, Gov. Jerry Brown signed a state law that now requires insurers to update their lists of doctors every seven days.
SB 137 also includes requirements that health plans make the directories publicly searchable on their websites, allowing consumers to comparison shop between insurance plans with up-to-date information. The directories should also note whether providers are accepting new patients, the languages providers speak and the office location of providers.
However, the websites of several California health plans, including insurance giant Anthem Blue Cross, have technological errors that make searching for providers difficult and may prevent Californians from finding a doctor.
In September, reporters revisited each of the websites for the six Medi-Cal health plans that were analyzed in the 2014 investigation. The Anthem Blue Cross website has a search page for Medi-Cal plans, which allows consumers to find doctors. However, when an additional search box is checked on the results page to specify for “Accepts Medicaid,” the federal name for Medi-Cal, the search engine returns no results.
Reporters found technological issues on websites for two of the other health plans that could also impinge on access. The California Health and Wellness online provider directory returns 538 results for primary-care physicians who are accepting new patients in Imperial County, but some of them are more than 450 miles away. And the search function on the website for CalViva Health, which has plans in Fresno, Kings and Madera counties, does not allow users to search for a doctor that can serve as a primary-care physician.
California health advocates say that the problems with the directories extend beyond the web search functions to the accuracy of the data itself.
As part of a research project for Children Now, Odeh inadvertently discovered in August that provider directory information for health plans in Imperial and Nevada counties contained inaccuracies, he said.
“One provider had an area code for a different part of the state,” Odeh said, “and when you call it, it’s not actually that provider.”
Other inaccuracies included physicians who were listed as practicing at a clinic but didn’t actually work there. “We would call the clinic and ask for Dr. Jones, for example, and they would say Dr. Jones is not here,” Odeh said. Some phone numbers led to doctors who either didn’t accept Medi-Cal or weren’t taking new patients, he said.
“We heard from the grapevine that there’s still a lot of inaccuracies,” said Betsy Imholz, special projects director for Consumers Union. Advocates from Health Access, the California Pan Ethnic Health Network, Family Voices of California and the Western Center on Law and Poverty also said they have continued to receive reports of inaccurate directories in recent months.
Health Plan Association Responds
The California Association of Health Plans, which represents 49 health plans in the state—the vast majority—said that some of the errors may be caused by doctors who don’t notify health plans of changes to their information.
However, the California Medical Association has said that doctors have reported that their practices are often listed erroneously even after they tell insurers that they are no longer accepting patients.
Health plans are working with providers, advocates and regulators to “further increase accuracy of directories for consumers and lessen administrative burdens on providers,” said Health Plan association spokeswoman Mary Ellen Grant.
“Health plans are actively reaching out to the providers in their networks to verify directory information and we encourage doctors throughout the state to work with health plans to provide timely updates,” she said.
Anthem Blue Cross did not reply to requests for comment.
Beginning in January, as part of SB 137, health plans will be required to use uniform standards for their provider directory information, which may fix some of the discrepancies in the lists and online searches. The standards will require directories to list a providers’ practicing addresses, phone numbers, whether they are accepting new patients, languages they speak and the type of insurance the office accepts, among other information.
Odeh is also hopeful that new federal rules for Medicaid programs may result in more oversight of the directories.
SB 137 also gives consumers some recourse if they have relied on provider directories to make health care decisions and those directories later turn out to be inaccurate.
If a patient has relied on “inaccurate, incomplete or misleading information” in a directory, the state Department of Managed Health Care may require the health plan to reimburse the patient for any extra costs, said spokesman Rodger Butler.
The agency, which regulates insurance companies, has resolved 33 such complaints since the law requiring updated directories took effect in July 2016. Of the complaints, three were for Aetna Health of California, Inc.; 14 were for Anthem Blue Cross; 13 were for Blue Shield of California; two were for Health Net of California, Inc.; and one was for L.A. Care Health Plan. The agency was not immediately able to release details of the complaints.
In 2015, the Health Care agency issued a $250,000 fine to Anthem Blue Cross and a $350,000 fine to Blue Shield of California because of inaccurate provider directories.
Although the department asks health plans to demonstrate how they are updating their directories, the agency isn’t required to check the doctor lists for accuracy as part of SB 137.
That means that the burden of correcting inaccuracies may be falling on patients, who often don’t have time to complain to the health plan or regulators, especially if they are searching for urgent medical care, Odeh said.
Jackie knows how this feels. Eventually, after several weeks of trying to find a primary-care doctor, she went to urgent care. By that time, the rash had begun to resolve, and there was little the doctor could do.
“Maybe your primary-care doctor could do a biopsy,” the urgent care doctor said. When Jackie finally got in to see a primary-care physician the following week, the rash was nearly gone, and the doctor said the window for doing a biopsy had closed. She still doesn’t know what caused the rash.
If consumers notice inaccurate provider directory information, they can report it to the health plan. If inaccuracies result in problems for consumers, the Department of Managed Health Care recommends that they file a grievance with their plan. Consumers Union also suggests keeping detailed records of any problems.
If consumers are not satisfied with their health plan’s resolution of the grievance or have been in their plan’s grievance system for 30 days, they should contact the Health Care department’s Help Center for assistance at 1-888-466-2219 or online at www.HealthHelp.ca.gov.