Pennsylvania Reminds Health Insurers to Keep Provider Directories Up to Date

September 24, 2015

Pennsylvania Insurance Commissioner Teresa Miller is reminding health insurers that they must keep their provider directories up to date and that consumers should not pay higher out-of-network costs if they use a health care provider who is out-of-network but, at the time the service was provided, was listed in their insurer’s provider directory as in-network.

Miller said Monday that Gov. Tom Wolf’s administration is working to ensure that consumers are protected from common unfair insurance practices. “Since it is the insurers’ responsibility to keep their provider directories up to date, my department will use its authority under the Unfair Insurance Practices Act to see that consumers who do their homework to make sure that the doctors and hospitals they are using are in their insurance network will not suffer financial harm just because those directories are out of date,” the commissioner said.

Miller noted that Pennsylvania law prohibits unfair or deceptive acts or practices by insurers, including publishing or circulating an advertisement, announcement, or statement which is untrue, deceptive, or misleading. She said that if a person receives health care services from a provider listed in the insurer’s provider directory as in-network, and the insurer then attempts to settle that claim as if the provider were out-of-network, her department will consider this to be an unfair claim settlement practice.

“The provider directory must be a source on which consumers can rely for critical health care information,” said Miller. “We have received complaints from people who have undergone major medical procedures, thinking the doctors and hospitals they used were in-network, only to receive surprise bills of hundreds or even thousands of dollars.”

Miller reminded insurers that since open enrollment begins for many health plans on Nov. 1, now is a good time to ensure their provider directories are up to date. The Insurance Department said it will examine the overall issue of surprise balance billing at a public hearing on Oct. 1 in Harrisburg, Pennsylvania.

Miller advises that any Pennsylvania consumer who receives health care services from providers listed in their insurer’s directory as in-network when the services were provided, and are later told one or more of these providers was out-of-network, should contact their insurance company. She said if the insurer does not agree to cover these services at in-network rates, the consumer should contact the Insurance Department.

Source: The Pennsylvania Insurance Department

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