SCOTT SIMON, HOST:
Maybe this has happened to you. You need a doctor. You might consult the provider directory on your health insurer's website to make certain that your care is covered. But a new investigation in the online publication The Lever finds that those lists may not always be accurate, and that has adverse effects for people who read that they are covered on the insurer's website. Helen Santoro reported the story and joins us now from Colorado. Helen, thanks so much for being with us.
HELEN SANTORO: Thanks for having me.
SIMON: These are the directories that say, find a health provider in your area, right?
SANTORO: Exactly. They are the directories that someone might go on when you're looking for a new provider and you want to make sure they're in-network with your insurer.
SIMON: Insurers use these directories, too - right? - but for a different purpose.
SANTORO: Yes. Insurers commonly seem to use these directories as a means to determine reimbursement rates. Let's say a provider is wanting to up the amount that an insurer pays them per patient visit. They might say, hey, I think I want $75 instead of 70. The insurer can then look to their directory and be like, well, we have 10 other providers that are getting $70 per patient visit, so we don't really need to up your reimbursement rates.
SIMON: I gather a specific case set off your investigation.
SANTORO: So I sprained my own ankle and started talking to my local physical therapist. She noted that she was having issues with her in-network provider with UnitedHealthcare, gave me the list of in-network providers. And I started looking into it, driving around to these places, and noticed, yeah, some of these places are not actually other physical therapy clinics. One was a dentist. The other was a park in a senior living community. The other was a home in a mobile residential area. So it was quite shocking, just from my reporting, that - yeah, these places that are listed on the in-network directory are not always the clinics that they claim to be.
SIMON: Why are they listed? Or is that a naive question?
SANTORO: No, I don't think it's a naive question, and I think it's one of the million-dollar questions with this. Why are they listed? Some of these places looked like they used to be physical therapy clinics that went out of business. Some of them are chiropractors or other clinics that provide services, but not physical therapy, so it's still not accurate. And some of them - I honestly do not know why they are listed. But clearly, this would cause issues for patients and providers alike.
SIMON: Well, what kind of issues?
SANTORO: Well, from the patient side, I mean, just think about when you're trying to find a new provider - you're depending on this list to make sure that you're getting covered and you're not getting a surprise bill in the mail later on. So if this list is inaccurate, that's going to impact how much patients are potentially paying out-of-pocket for services that an insurer claimed were covered.
SIMON: We contacted UnitedHealthcare. A spokesman said your story had several inaccuracies. We asked for specifics. What did they say to you?
SANTORO: Similar. I reached out to the contract manager who works to actually negotiate these rates with providers - never heard back. I reached out to a UnitedHealthcare spokesperson - similar story that there's inaccuracies. When I pushed for what inaccuracies there were, didn't hear back anything. So I would love to hear what inaccuracies they claim there are because, from my reporting and speaking to providers, this seems to be quite an issue.
SIMON: Does UnitedHealthcare, best as you can determine it, stand alone?
SANTORO: No, not at all. This is an issue that really spans the gamut of health insurers. In fact, the U.S. Government Accountability Office looked into this a few years back and found that people with mental health coverage are experiencing challenges finding in-network providers in large part because of these inaccurate and out-of-date provider directories. And they noted the term ghost network - so providers who are listed as in-network but are either actually not taking new patients or not really in the insurer's network. So this is an issue across all insurers.
SIMON: Helen Santoro is a reporter for The Lever. Her new investigation into insurer directories of providers was published this week. Thanks so much for being with us.
SANTORO: Thank you so much for having me.
SIMON: And UnitedHealthcare has not provided details to NPR about what was inaccurate in the Lever article. A spokesman did tell us that they depend on providers to let them know when they move or stop accepting insurance. He said that, once notified, the company will update its directory within hours. Transcript provided by NPR, Copyright NPR.
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