According to a new state report, California's biggest health insurers are reporting inaccurate information about which providers are in their networks. As a result, 36 of the 40 reviewed providers could face heavy fines from the state for not complying with state rules.
What does this mean for patients insured by these companies? In many cases, it can result in patients unknowingly going out-of-network for care, resulting in denial of coverage by the insurance companies.
California officials discovered this problem when reviewing annual reports that were filed by health care insurers, as required by law. They found huge discrepancies between the provider lists use to measure patient access throughout the year and their final tallies. In many cases, the state's report noted, the discrepancies included several thousand physicians.
"Their inability to accurately document which providers are in their networks raises serious questions about the reliability of these networks," said Sen. Ed Hernandez, chairman of the state Senate Health Committee.
Patients who are billed for providers they thought were in-network do have recourse against the insurer. You have at least 180 days from the date you received the bill to file a grievance with the insurer. Insurers then have 30 days to investigate your claim and, if they find a discrepancy, they need to correct the bill or reimburse you the amount beyond what you would have paid in-network.
If the insurer denies your grievance claim, you have the option to take your complaint further. Depending on your plan, you can take your case to the Department of Managed Health Care or the Department of Insurance. At this point, it may be in your best interests to discuss your case with an attorney with experience with bad faith insurance claims.