When the PPO directory is wrong

[Guest kchristy]

A client of mine just experienced the following problem: She needed a particular type of surgery, so she consulted that specialty section of her PPO directory. She then visited the doctor, presented her membership card, and was told that yes, they "accepted" this carrier, and even estimated for her how much the insurance would pay.

When the claim went through, it turned out that the carrier had not had a contract with the provider for almost five years, through they continued to print his name in the directory.

In the directory, the carrier has a section up front called "To Visit a PPO Provider." In it, they outline a three step process:

1) Review your plan to make sure that what you want done is covered;

2) Call a provider from the directory and identify yourself as a PPO participant and confirm that they are currently participating with the PPO network;

3) Present your PPO card at the time of the appointment.

The client did all this, yet still the claim was processed as non-PPO. We are currently appealing that, but has anyone else run into a similar situation?

[Guest SG]

As a TPA, we would definitely process that claim as in-network. The reasonable expectation is absolutely correct. It is not the EE's responsibility to ensure the accuracy of the directory, especially from 5 years past!

This has happened several times with our clients (the ppo's furnish thier own directories in our case) and we have always paid as in-network benefits.

Hope this helps.

[Guest jreddi]

I have run into this several times.

Our PPO allows three ways for ees to check a provider against current provider listings: first, through the printed directory; second, through the claims office via telephone; and, third, through the carrier's website.

It seems, though, that any one time, these three do not carry current information. Based upon what I would call a "reasonable expectation" on the part of the employee that the information in the directory was correct, especially since the carrier assumed the liability for printing a provider listing that hadn't been in effect for five years, I would go back to the carrier. Given that five years is an unreasonable amount of time to have a incorrect provider listed, your carrier should just have this claim paid in-network. My relationship with my carrier is suce that they will process these claims accordingly.

[Brigid Anderson]

Can't believe your client won't prevail if the facts are as straightforward as you describe. Check the proposed DOL regulations on SPD contents (DOL Prop. Reg. 2520.102-3, 63 Fed. Reg. 42379, issued 9/9/98) which would add to the items required in a group health plan's SPD:provisions governing the use of network providers, the composition of the provider network and whether and under what circumstances coverage is provided for out-of-network services. The required listing of providers may be furnished separately from the SPD but the SPD must contain a general description of the network and indicate that the separate listing is provided automatically without charge.

While these are proposed regs, the DOL says in the preamble (found at the above Fed. Reg. cite) that it considers this item is already required by current regulations.

So, the list of providers should already be in the SPD. SPDs must be updated every 5 years (if there's been any amendment) and summaries of material modification are required for changes in the interim.

There are plenty of cases out there that say the SPD controls over an inconsistent plan document particularly where as here the participant relies to her detriment on the incorrect SPD. See, e.g., Chiles v. Ceridian Corp., 95 F.3d 1505 (10th Cir. 1996).

Now as between the plan and insurer, the liability issue turns on different considerations. I expect the result will depend on who is responsible for keeping the SPD up to date and issuing SMMs.

Hope this helps.