California was one of the leaders in the health maintenance organization (HMO) movement, and in the managed care provider network movement.

Members of a major medical society in the group, the California Medical Association (CMA), want the state to be a leader in keeping provider directories up to date, and in keeping doctors from ending up in provider networks they never intended to join.

The plans and their network builders argue that they need the flexibility to create small, high-volume networks of cost-effective doctors to help keep premiums low and the quality of care high without limiting patients’ access to care. The plans also say they face antitrust concerns, such as a need to avoid the perception that they are colluding with providers to prop up health care prices.

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A probe by California investigators who were highly critical of some plans’ provider directories found that a majority of the entries in directories it tested were correct.

But the providers argue that, in their market, the current system could swamp some providers with patients with very low plan reimbursement levels and high red-tape requirements. If that keeps up, the providers say, unrealistic contracting strategies could backfire, by reducing the number of providers who are able to keep their offices open and reducing access to care.

Brett Johnson, a CMA representative, presented some ideas for making providers happier with network contracting in a comment sent to the board of Covered California, California’s state-based public exchange.

For a look at some of the CMA ideas for improving network directories and network contracting, read on.

Listening dog

1. The association says insurers should listen to doctors better, and act on what doctors say

Johnson says the CMA already tries to share information about network contracting or directory problems with the plans when it learns about the problems, but that the plans rarely seem to result in changes.

One way insurers could improve the situation would simply be to work with the CMA or Covered California to communicate better, let physicians know about directory update procedures, fix any physician notices that happen to be confusing.

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Hand signing documents.

2. The association wants plans to get doctors’ permission before putting them in a new type of network

Today, Johnson says, many providers have contracts that require them to participate in all of an insurer’s networks if they want to participate in any of the networks.

In many cases, the contract also lets an insurer makes a “silent amendment” to a contract, and to assume that a provider’s silence about an amendment means the provider has accepted the change.

The result is that physicians may end up in narrow networks or low-reimbursement networks without realizing that they are in those networks, Johnson says.

“Ensuring that there is an understanding and acknowledgement of participation up front for the physician can largely eliminate the potential for lingering confusion over participation status down the road,” Johnson says.

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Data

3. The association would like to see its plans provide tools providers can use to update their own provider directory information, and for its state’s public exchange to create a cross-plan provider directory

Johnson says giving providers the ability to update their own directory entries would be a great way to reduce updating delays.

Setting up a tool that would let exchange users search plans by the name of a provider, and then see what plans the provider was in, would help consumers shop for coverage and would also help physicians update and correct their directory entries, Johnson says.

A “cross-plan directory” could help a physician spot inaccurate entries and duplicate entries, Johnson says.

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