The California Department of Managed Health Care found ninety person ( 36 out of 40) healthplan/insurance company department compliance reports for 2015 contained data inaccuracies significant enough to render them essentially usable and certainly not consumer friendly.
This story originally appeared in California Healthfax and then reported on in HealthLeaders. From HealthLeaders
A state review of provider directories and compliance reports supplied by insurers found most insurers had conflicting information on the number of physicians in their provider networks.
The California Department of Managed Health Care (DMHC) issued a report that found that 36 out of 40 Timely Access Compliance Reports submitted by insurers for 2015 contained “significant data inaccuracies” to the degree that they were not usable.
“Ninety percent of the 2015 Timely Access Compliance Reports submitted to the DMHC contained one or more significant data inaccuracies, making it virtually impossible for the DMHC to measure individual health plan compliance and compare plans across the industry,” the report stated.
As part of its review, the DMHC compared the identity of primary care physicians (PCP) in each insurer’s Compliance Reports and Provider Rosters, with one providing a list of physicians available to members during the year and the other a year-end summary of providers.
The reports listed a significant percentage of PCPs who were not actually part of the health plan’s own network of providers, based on the information provided by the plan through its Provider Roster, according to the review.
Care 1st Health Plan had the highest percentage of physicians listed in the compliance report but not listed in the plan’s provider roster, at 56%, the DMHC report stated. UnitedHealthcare of California had a rate of 45% , and 43% of physicians listed on Health Net’s compliance report were not on the plan’s provider roster.
Blue Shield of California had the lowest percentage at 22%. Others with low percentages including Cigna (36%), Anthem Blue Cross (36%), and Aetna (29%).
“Health plans that failed to follow the mandatory DMHC methodology or submitted inaccurate or erroneous data … violated California’s health plan law, known as the Knox-Keene Act,” and could face fines, the report stated.