The merger left Hannah Hale with no other choice.
In January 2021, the Digestive Health Association of Dallas joined forces with the Texas Digestive Diseases Consulting Company to form the GI Alliance, a specialty group comprised of nearly 700 gastroenterologists in 14 states. state. GI Alliance and her health insurer, Cigna, failed to reach an agreement. But Cigna didn’t update its vendor directory.
As for the Centers for Medicare and Medicaid Services, it appears that the GI Alliance is part of Cigna’s Medicare Advantage network and the insurance company complies with the network coverage requirements. In fact, Hale, 35, said she struggled for two years to find a gastroenterologist in the area willing to accept her Cigna contract.
Hale said: “I felt like a madman, wearing a tin hat because it looked like Cigna was doing the wrong thing on purpose. “Every patient in the Dallas area who sees a GI doctor in my plan loses access to GI care. Their directory is full of errors.”
A company spokesperson wrote in an email that privacy laws prevent Cigna from discussing Hale’s specific experience. But the insurer met all network coverage standards in the Dallas area, the spokesperson wrote. “We regularly update our supplier directory. … Vendors may be listed incorrectly at times, and we work to resolve these issues whenever they arise.”
CMS requires Medicare Advantage insurers to update their provider directory quarterly. But Hale’s difficulties with Cigna illustrate the sad state of the supplier list.
Nearly half, or 48.7%, of the Medicare Advantage plan category scored incorrectly in 2018, according to the most recent federal assessment. Regulators have proposed rules to crack down on shadow listings and even suggested the creation of a national supplier directory.
Instead of insurers loading a provider’s contact information, availability, and more into different systems, providers would log into a centralized data center to import the information. their website, according to a CMS proposal launched in October. Public and private payers would then use those data to assemble their own directories.
CMS cited a Council on Affordable Quality Healthcare study that projects converting bibliographic data collection to a single platform could save physicians 1.1 billion dollars in annual administrative costs. “ONE [national provider directory] both can streamline existing data on CMS systems and public information in a format that is easier to use than is currently available,” the agency wrote in the request.
Nearly every stakeholder doesn’t like the idea.
The American Hospital Association wrote to CMS last month that not every health system operates the technology needed to support this initiative. The hospital’s lobbying group expressed skepticism about its ability to reduce administrative burdens and suggested that the initiative would overlap with existing federal reporting requirements, “must admitted that there were many inaccuracies.” The AHA has asked CMS not to proceed with the plan.
“Adding an additional data source without fully addressing how or why it differs from the multitude of already existing vendor directories can further complicate your ability to access accurate information. patients,” wrote the AHA. “Meanwhile, such a request would add [a] significant, duplicated burden on suppliers.”
Insurers are concerned that they will be held accountable for continually verifying the accuracy of service provider information.
“The federal government can’t say, ‘I’m going to push this responsibility down to the health plans because I can’t figure out how to make a national directory that works.’ That doesn’t lead to anything meaningful, said Michael Bagel, public policy director at Alliance for Community Health Plans, a trade group for nonprofit insurers.
CMS currently relies on insurance companies to regulate themselves when it comes to provider directories. The agency’s inability to hold companies like Cigna accountable for its rules makes Hale skeptical of another new requirement by regulators.
Hale applied for disability benefits and tried to devote full time to managing her health. She suffers from a variety of genetic and autoimmune disorders, including gastrointestinal disease, Crohn’s disease, and Ehlers-Danlos syndrome, a connective tissue disorder. The treatment of these conditions has led to side effects such as short bowel syndrome, arthritis and mast cell activation disorder, an immune disease, she said.
When Hale initially qualified for a disability in 2016, she signed up for traditional Medicare because their extensive network would give her access to many of the specialists she needed. But because Texas law forbids people with disabilities from buying additional Medicare coverage, she soon found the fee-for-service plan was costing her too much herself.
In 2017, Hale’s pharmacist suggested Medicare Advantage as a way to cover her out-of-pocket costs, she said. Hale makes a spreadsheet that lists all the doctors she’s visited and the insurance plans they accept, then searches for the most duplicate policies. She signed up for the Cigna Preferred Medicare PPO, which limits her to one network but will provide some level of coverage for visits with out-of-network clinicians.
Hale says that the first four years with Cigna were generally positive. “Insurance is supposed to be tough and they have to make it difficult for you when you need everything approved, and that’s not my experience with them,” she said.
That changed in October 2021, when Hale’s longtime gastroenterologist at Digestive Health Associates refused to see her, writing in an email that after the merger with the GI Alliance, he was unable to treat for the Cigna members too. She worries that her complicated situation will make it difficult to find a replacement.
“The GI Alliance joins the all-big-payer network in the markets where they provide care,” the spokesperson wrote in an email.
The announcement from her gastroenterologist surprised Hale. CMS requires Medicare Advantage providers to notify patients—and update their online provider directory—within 30 days of the network change.
Hale says she didn’t hear a peep from Cigna. She checked Cigna’s provider directory, which said every gastroenterologist in the network within 75 miles of Dallas was affiliated with the GI Alliance. When she called the insurance company to make a complaint, she spoke to three customer service representatives, all of whom refused to believe that GI Alliance had no network, she said.
“Their inability to see what the situation really was compared to what was on their computer screen prevented me from accessing the GI care my condition required,” Hale said. “I need help, and the person said she has no way to update the provider directory, she has no way to take this call to a higher level, she has no way to do anything. whatever and we just have to wait.”
Hale said that despite more complaints calls with Cigna, the insurer had yet to update its list in December.
Hale decided to appeal to CMS.
When patients file complaints about Medicare Advantage insurers with federal regulators, CMS records them in a tracking module and forwards the information to providers along with instructions. problem solving guide. Insurers usually have one month to fix problems and have the sole discretion to declare claims resolved at their sole discretion. Because carrier bonuses through a star rating quality program depend in part on how they respond to member claims, insurers have a financial incentive to flag cases is closed.
Regulators may impose fines, freeze subscriptions, or issue other penalties against Medicare Advantage insurers that fail to comply with provider directory standards. CMS did not do that in this case and never responded to Hale’s complaints after passing them on to Cigna. “They never did anything to enforce it,” Hale said.
CMS says they have nothing to enforce. A CMS spokesperson wrote in an email that Cigna adheres to network coverage standards for gastroenterologists in the Dallas area. The insurance company provided Hale with network specialists, and Hale agreed to contact a new provider to make an appointment, according to the agency.
“CMS verified that the plan contacted the customer and provided the names of the Dallas metropolitan area physicians who were in the network,” the spokesperson wrote.
CMS reviews Medicare Advantage plan networks every three years and has asked their regional office to review Cigna’s contract for the Dallas area this year. The agency said that request is pending.
The day after Hale contacted Medicare, a Cigna representative called and explained that the directory was out of date because the insurance company hadn’t updated the gastroenterologist’s login information. upon the merger, which is why they are still listed incorrectly in the network, Cigna employees said, according to Hale.
Despite more text and phone communications, it was the last useful piece of information Hale received from Cigna in months, prompting her to appeal again to CMS in March 2022. responded the following month with the names of 13 network gastroenterologists who were not affiliated with the GI Alliance and subsequently removed most, but not all, of the providers from that operation from their directory. it.
Many of the doctors Cigna identified, she said, were either not accepting new patients or refusing to meet someone with complex needs like Hale’s. One serves only Veterans Health Administration beneficiaries. Hale found a nearby in-network gastroenterologist who agreed to renew her medication but would not accept her as a long-term patient, she said.
Hale again complained to federal regulators in May and June about Cigna’s supplier directory. That summer, Cigna sent her two more letters saying that they had tried to call her and asserting that she had twice verbally agreed that the company had resolved her problems. . “Our investigations concluded that proper process was followed in the processing of your complaint,” Cigna wrote in August 2022.
Medicare Advantage members can switch plans that change their network at any time, not just during open enrollment. That won’t help Hale because the insurer’s failure to notify CMS of changes to their network means she has no good reason to qualify for a special subscription. Hale also did not leave Cigna during open enrollment because she appreciated the out-of-network coverage the PPO provided. “It was hard trying to find a plan that included my different specialists without losing access to them,” she said.
