The Washington PostDemocracy Dies in Darkness

The Health 202: Obamacare plans face lawsuits over erroneous doctor directories

with Paulina Firozi


Obamacare health plans have been criticized for severely restricting the doctors and hospitals that patients can see. But sometimes even those limited provider lists are riddled with errors, causing additional headaches for patients who had purchased a plan hoping to keep their physician only to later discover that doctor isn’t fully covered by insurance.

Marketplace insurers are fighting lawsuits from consumers in four different states who say they were misled about which health providers were covered under their plan. It wasn’t until after purchasing the plan, these patients allege, that they learned their doctor or hospital was outside its network and therefore covered only partially or not at all.

We wrote in December about the problem of inaccuracies in the medical provider directories of Medicare Advantage plans. But it’s a more widespread problem, affecting the commercial health plans purchased by tens of millions of Americans every year and leading to unexpected extra costs.

Many people — especially those with chronic conditions needing regular medical care — base their choice of insurance coverage on whether a particular health plan includes their preferred doctor in its network of providers. There are expensive consequences if not, as patients typically must foot more of the bill if they receive care from an out-of-network doctor or hospital.

“This is a problem across insurance markets and most health plans,” said Michael Adelberg, who formerly worked at the Centers for Medicare and Medicaid Services and is studying problems with provider directories with a grant from the Commonwealth Fund. “There’s a lot of good reasons why getting these directories accurate is hard.”

— Two residents of Texas and Washington state are suing insurer Centene, saying the company’s Ambetter plans misrepresented the number, location and existence of in-network providers, even listing the names of nurses and medical students as primary-care doctors. It wasn’t until after they purchased the coverage that they learned of the limitations, the plaintiffs charge.

“Ambetter policyholders around the nation report strikingly similar experiences: After purchasing an Ambetter insurance plan, they learn that the provider network Centene represented was available to Ambetter policyholders was in material measure, if not largely, fictitious,” the lawsuit says.

“Members have difficulty finding — and in many cases cannot find — medical providers who will accept Ambetter insurance,” it continues.

— In a lawsuit against Anthem Blue Cross Blue Shield, two residents of Cobb County, Ga., say they purchased an Anthem marketplace plan during last year’s enrollment period specifically because the plan advertised the area’s WellStar hospital network as part of its provider network.

A few months earlier, Anthem had told WellStar it wouldn’t be in network for the upcoming plan year — but the patients said they weren’t made aware of the change while buying the plan. “Anthem concealed this material fact from consumers for the purpose of inducing them to select Anthem as their healthcare provider,” the lawsuit says.

— And in a third lawsuit, filed in Ohio last week, residents of the state say they bought CareSource plans on the state’s marketplace that were more expensive than they would have otherwise purchased, if not for the plan’s purportedly expansive in-network offerings. They say the insurer has a pattern of publishing “fraudulent and negligent misrepresentations” of the accuracy and size of its provider directory.

Error-ridden provider directories are just one issue in a whole basket of persistent consumer difficulties with health insurance gaining increasing attention from policymakers. A bipartisan group of senators has said it plans to release a bill by the end of the month dealing with the surprise medical bills patients can get after unexpectedly receiving care from an out-of-network provider.

Last month, as part of a massive regulation around the transmitting of electronic health information, the Trump administration proposed some new requirements for how insurers should post provider information online.

States are trying to tackle the problem, too. The California Department of Managed Health Care and Blue Shield of California are overseeing the development of a statewide provider directory, with the aim of creating one centralized database where providers and plans can exchange information.

In Washington state — which fined Centene $1.5 million in 2017 after receiving 140 complaints about misleading provider directories and insufficient provider networks — legislators may soon approve a bill to require more transparency from insurers about which medical providers are in network.

Steve Valandra, deputy commissioner for public affairs for the state’s insurance commissioner, told me Centene’s executive team met with state regulators last week and appeared to be diligently working on fixing its directory and network problems.

“They’re doing a hell of a lot better,” Valandra said. “Correcting their networks, contracting with more providers, all the areas where they were deficient.”


AHH: The software tool the Trump administration is using to determine eligibility for its program to expand private medical care for veterans is flawed, an independent review has found. The flawed tool “threatens to disrupt the health care of about 75,000 veterans every day,” ProPublica’s Isaac Arnsdorf reports.

The review was conducted by U.S. Digital Service, a group of software developers enlisted by the White House to help federal agencies with their technology. The group concluded the Department of Veterans Affairs should toss the current eligibility tool and start over with a new one.

“The USDS report raised concerns that the eligibility tool was designed in a way that wouldn’t work for VA doctors,” Isaac writes. “The report predicted that the tool would generate errors or run slowly or crash. These glitches would lengthen each appointment by five to 10 minutes, the USDS team estimated, which equates to being able to treat 75,000 fewer veterans every day systemwide.”

A VA spokesman declined to comment to Isaac on the review but said it “remains a work in progress.” Rep. Mark Takano (D-Calif.), chairman of the House Veterans Affairs Committee, called the findings “incredibly alarming” and said his committee would hold a hearing on funding VA has requested to complete work on the eligibility tool.

OOF: Anti-vaccine activists have taken to targeting doctors online, as public health advocates have pointed to social media as platforms for the spread of vaccine misinformation, the Los Angeles Times’s Soumya Karlamangla reports.

More than 50 online campaigns against health-care providers who promote vaccines have ocurred since late 2017, according to Chad Hermann, communications director for Kids Plus Pediatrics, a Pittsburgh practice that started tracking these online attacks after it was the target of one itself.

Hermann told the LA Times it’s important to teach doctors how to deal with web-based tactics as social media become sources of information for parents trying to decide whether to vaccinate their children, Soumya writes.

She writes about one doctor who posted on Facebook encouraging patients to come to her office for a flu shot. The doctor was bombarded with comments from anti-vaxxers. She also received low online ratings from people she hadn't treated and was called a "child killer.”  

“When pediatric practices are being … terrorized into silence, it’s going to create a void in the discourse,” Hermann said. “And we all know who’s going to fill that: the anti-vax folks.”

OUCH: New data from the Centers for Disease Control and Prevention show about 80 percent of new HIV infections in 2016 were spread by people with HIV who were diagnosed but not being treated, or who did not know they were infected.

The report, based on information about the 1.1 million people in the United States living with HIV in 2016, was published in the CDC’s Vital Signs report on the first day of the National HIV Prevention Conference. It found 38 percent of transmissions occurred from about 15 percent who had an undiagnosed HIV infection.

It also found 23 percent of people had a diagnosis but were not getting treated, a group linked with 43 percent of the new transmissions in 2016.

The report comes as the Trump administration has called for $291 million in funds for its domestic effort to stop the transmission of HIV within a decade. Trump’s 2020 budget request includes $140 million in new funding for the CDC to reduce new HIV infections with improved testing, prevention efforts and medical care referrals, our Post colleague Lena H. Sun reports.


— Primary-care doctors and specialists are embracing electronic consultations as a way to assist patients quickly and help them avoid additional office visits, the New York Times’s Austin Frakt reports.

The result of using these eConsults, or eReferrals, can “free up capacity in crowded health systems, reducing waiting times for others." 

“Here’s how eConsults work. When a question arises that your primary care doctor can’t answer without advice from a specialist — whether an M.R.I. for knee pain is warranted, for example, or how to interpret a test result — she messages a specialist reviewer for help,” Austin writes. “That reviewer engages in an electronic dialogue with your doctor to gather information and decide if the issue can be addressed without a separate visit. Often it can be.”

At the Los Angeles County Department of Health Servies, where eConsults were adopted in 2012, a study found that by 2015, wait times for certain specialists dropped an average of 17 percent, going from 63 days to 52 days. It also found a fourth of eConsults engagements between primary care doctors and specialists "were resolved with no visit at all." 


  A high-school student’s family in Northern Kentucky is suing a local health agency after he was banned from school because he did not have a chickenpox vaccine.

Bill Kunkel, the father of 18-year-old Jerome Kunkel, told local station WLWT that his son was being discriminated against because of their Christian faith. “I don't believe in that vaccine at all and they are trying to push it on us,” Bill Kunkel told WLWT.

They’re suing the Northern Kentucky Health Department after the agency said students who weren’t vaccinated needed to stay home from school for three weeks amid an outbreak of chickenpox at the school.

Jerome Kunkel told WLWT it was “devastating” to be banned from school.

"The recent actions taken by the Northern Kentucky Health Department regarding the chickenpox outbreak at Our Lady of the Sacred Heart/Assumption Academy was in direct response to a public health threat and was an appropriate and necessary response to prevent further spread of this contagious illness," the health department said in a statement responding to the lawsuit.

“Unfortunately, some individuals, including the attorney who filed the lawsuit, have taken to social media to spread misinformation as part of their litigation strategy. It is unfortunate when social media is used as a weapon for misinformation to advance litigation agendas and to undermine our mission to protect public health.”

— And here are a few more good reads: 


Cory Booker blasts ‘senators bragging about their pot use’ (Felicia Sonmez)

House Dems to take up gender pay gap, domestic violence laws (Politico)


Kellyanne Conway dismisses her husband’s concerns that Trump’s mental health is deteriorating (John Wagner)

New Doubt on Treatment to Prevent Preterm Birth (Wall Street Journal )

More U.S. youth seeking help during psychiatric emergencies (Reuters)

The Fertility Doctor’s Secret (The Atlantic)


Purdue Pharma wants to ban cameras in Oklahoma opioid trial to avoid "media circus" (Axios)



  • The 2019 National HIV Prevention Conference in Atlanta, Ga. continues.
  • The Brookings Institution hosts an event with outgoing FDA Commissioner Scott Gottlieb.

Coming Up

  • The CATO institute holds an event on harm reduction on Thursday.
  • The Bipartisan Policy Center holds an event on overcoming health care challenges in immigrant communities on Thursday.
  • The Brookings Institution holds an event on emerging policy solutions to surprise medical bills on Friday.

From the Fact Checker: Several Democrats suggest many Americans have to work multiple jobs. Do they?

Despite good economic news, prominent Democrats suggest many Americans are still working two or three jobs "to pay the bills" and "to survive." (Video: Joy Sharon Yi/The Washington Post)