Health insurers face fines starting Jan. 1 for mistakes in provider directories

Heads up: Health insurers could face some steep fines starting Jan. 1 for mistakes in their provider directories.

New regulations that take effect Friday, with the start of the new year, will allow the Centers for Medicare & Medicaid Services (CMS) to impose penalties on insurers of up to $25,000 per beneficiary for errors in Medicare Advantage plan directories and up to $100 per beneficiary for errors in plans offered on the federal insurance exchange Healthcare.gov, according to The Wall Street Journal.

CMS notified insurers of the stricter provider directory rules for 2016 in letters sent last February. The requirements were put in place after many Affordable Care Act plan enrollees struggled to find doctors who would accept them as patients and complained plan directories were inaccurate. Some consumers also faced surprise out-of-network costs when they were cared for by providers mistakenly listed in directories.

States also have their own regulations and fines. Two health insurance companies, Blue Shield of California and Anthem Blue Cross, were fined in November by California insurance regulators for misleading consumers about their physician networks on that state's insurance exchange.

Now with federal penalties on the horizon, many insurers have been scrambling to update their directories. "Plans are calling doctors' offices by the day, by the hour, by the minute," Clare Krusing, a spokeswoman for America's Health Insurance Plans, told the WSJ. But, she added, oftentimes providers aren't cooperative and won't call insurers back, making it difficult to ensure up-to-date information in the directories.

Some insurers are working to establish a central database where physicians can update their information. Eight major insurers, including Aetna, CareFirst Blue Cross Blue Shield and United Health, launched a pilot program last summer that allows them to use data from the Council for Affordable Quality Healthcare (CAQH), which maintains a database with credentialing information, to update their directories, the WSJ reported. The CAQH plans to offer the service to all health plans in January, the newspaper said.

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