Medicare officials warn 3 Pa. health plans
Must fix physician network directories
Pittsburgh Post-Gazette
Medicare has warned three Pennsylvania health plans that sell coverage for seniors to fix their physician network directories by Feb. 6 or face fines or enrollment bans.
Highmark Health and its affiliate, Gateway Health Plan, both located Downtown, and Philadelphia-based Health Partners Plans Inc. were among 21 Medicare Advantage insurers warned by federal officials about high error rates in their online physician network directories.
The Centers for Medicare & Medicaid Services, which oversees Medicare, conducted the audit, which was the government’s first indepth look at the accuracy of provider directories.
The federal review focused on primary care doctors, heart specialists, eye doctors and cancer specialists. The CMS found that almost half of the 5,832 doctors listed had incorrect information in the directories, which members use to find doctors in their network.
Highmark spokesman Aaron Billger said the insurer had not received any complaints from members, but the carrier took immediate corrective action when it became aware of the problems last spring with its Freedom Blue PPO plan.
“We take it very, very seriously and immediately took action to address the issue,” Mr. Billger said. “It’s a national issue.”
Since then, Highmark has been conducting monthly internal audits of its provider directories. Freedom Blue has 35,000 in-network doctors in Pennsylvania and Highmark is looking for a contractor to routinely do the audits, Mr. Billger said.
In a prepared statement, Gateway Health spokeswoman Paula Yurkovich said the problem stems from doctors in a group practices sometimes being listed as staffing more than one office when they may only see patients occasionally at some sites. Gateway and Highmark have made thousands of calls to providers to verify staffing, she said.
Mercy Health System of Philadelphia and Highmark each own a 50 percent share of Gateway.
UPMC Health Plan received a notice of noncompliance from CMS for errors in its provider directory, but its deficiency score was lower than either Gateway or Highmark, which each received warning letters.
More than 17 million seniors, or nearly a third of Medicare beneficiaries, get coverage through private Medicare Advantage plans, which are offered as an alternative to traditional Medicare. Medicare Advantage penetration rates vary, but exceed 50 percent of eligible seniors in Allegheny County. Kris B. Mamula: kmamula@post-gazette.com, or 412263-1699.