Health Insurance Exchanges: Submit Comments on Accurate Provider Directories
The other trick often employed is to not differentiate between providers who only treat inpatients versus those who treat outpatients. Our hospital has full-time, inpatient-only psychiatrists who are always accepting new patients for admission but do not have an outpatient practice. We get 10-20 calls per day from frustrated patients trying to find an outpatient psychiatrist. Our attempts to get the plans to list us as inpatient-only have been unsuccessful. I once called all 30 providers in a patient’s directory to discover that only three would be able to accept her.
A much more reliable method of conveying more accurate information about a plan’s network adequacy would be to use claims data to indicate next to each providers’ listing some measure of the number of new outpatient claims (CPT codes 90801, 9920x, 9924x) submitted over the most recently available 12 months. This screens out the inpatient-only providers in addition to indicating those providers with no or low volumes of new patients. In the above example, 27 of the 30 providers would have a zero or single digit numbers, while the directory would clearly indicate that only three providers are responsible for most of the new patient appointments. The benefit to this method is that it requires little maintenance, is self-correcting, and exposes the phantom network such that potential enrollees would be able to more accurately assess the network adequacy prior to choosing that plan. It would require additional initial database and programming services to establish the links between the claims database and the provider database.
I invite readers to submit their comments or refinements to this suggestion here in the comment section. More importantly, I urge readers to submit a public comment on this NPRM to the Centers for Medicare and Medicaid Services at https://www.regulations.gov. Refer to file code CMS-9989-P, and specifically to Sections 156.230 and also to 155.1050, which states that “An Exchange must ensure that the provider network of each QHP offers a sufficient choice of providers for enrollees.”
-- Steven R. Daviss, M.D., DFAPA
Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter@HITshrink and at drdaviss@gmail.com.
