What’s next? How to make a change?

I work in customer service for a MCO, not stating which one but think like plans like Aetna, United, Sunshine. I work for the Medicaid division tho. I have worked with them in several different specialty areas like member service, renewals, web support etc. members= customers or clients Providers= doctors, specialists, nurses, care professionals

I have one major qualm with our company and that is OUR LISTED IN NETWORK PROVIDERS ARE NOT UP TO DATE.

I cannot believe how bad it is and it keeps getting worse. When I started here there was an internal system we used that had our providers listed in it. It would load in-network doctor/provider options using the members zip code that was on file, they would come up sorted by what was closest. Along with using that system we would call the providers office to confirm if they were still taking our plan and accepting new patients. We could use that same system to check a specific providers network status. Then we were told not to use that system anymore because it’s not up to date. Which most of us knew because of the calls we were making. Instead they wanted us to start using our member website to find in network providers for members and continue to call the offices to verify. Shortly later we saw that was also not very accurate either. Now we are being told that the website isn’t reliable and just call providers in their area to confirm who’s in network. Yes we can see who is contracted with us but a lot of the time we call their office to confirm and they say “no we do not take that insurance” , even though they are contracted with us. Legally they don’t have to take our patients even if they have a contract with us. It is our job as the insurance to provide reliable options to our members when they need help finding care.

We( customer service reps) are told (by all levels of management) the reason it’s hard to stay up to date is because a lot of the providers are contracted but are choosing not to take the insurance and also providers change their credentialing so often it’s hard to keep up.

So what is my company doing to keep up with in network providers taking our insurance so we can provide good options to our members? Nothing really. My coworkers and I have asked managers and directors and other departments if there’s anyway to get a more efficient way to help our members. We have really been given the same thing every time “ providers are constantly changing their information so just make sure you call and confirm if they are still taking the insurance before giving their information to a member”. Then if we call and still cannot find anyone taking the insurance we send it to a sort of escalations team that will basically call everyone in the members county until they find a provider accepting The insurance. It is embarrassing and INFURIATING that we as the people working for their insurance cannot find them someone taking the insurance. I cannot imagine how our members feel.

We are no small company either, we are enormous with plans in almost all 50 states and thousands of employees in just our Medicaid division. I am one small person at the bottom of the chain here but any ideas on what I can do to get my company to put some serious effort into resolution for this. I know that any solution or idea would require consistent updates but how do I get them to get it done? It’s not like putting effort into this could hurt our company, we have members leave our plan all the time for this exact issue. And they put effort into changing other things that are not broken and don’t need improvements.

If you have any ideas great, if not it was nice just to rant.

submitted by /u/Ok_Culture8514
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