Patients face misinformation from insurers when seeking coverage

A group hailing from the University of Michigan Medical School found widespread misinformation about Affordable Care Act (ACA)-mandated breast health coverage, using a mystery shopper who spoke with insurance representatives over the phone. The research was published in the Journal of the American College of Radiology.

Purporting to be a 40-year-old woman who previously underwent screening mammography and was notified she had dense breasts, the shopper asked about coverage for genetic screening and ultrasound for women with dense breasts, which are both required to be covered under the ACA.

Only 17 percent of the nearly 160 representatives they spoke to were able to provide breast health information consistent with U.S. Preventative Service Task Force guidelines, and 23 percent were unable to provide any coverage information at all.

“Insurers themselves are responsible for barriers and challenges to making a meaningful insurance choice,” the authors wrote. “Although the ACA mandates that coverage information provided by plans should have information about categories of coverage, cost sharing, deductibles, and copayments in a standardized summary of benefits and coverage format to increase patient comprehension, it remains difficult for the average insurance shopper to compare different plans.”

The shopper received plenty of “I don’t know” responses when asking about out-of-pocket costs for either procedure, even while the ACA mandates insurance cover the upfront costs. This can lead to patients purchasing plans that don’t match their needs, frequently overpaying to get coverage that should be free. This phenomenon was demonstrated in a previous study reviewing the ACA-required coverage of contraception.

However, the blame doesn’t rest entirely on the shoulders of insurers. Consumers demonstrated low insurance literacy when presented with information about cost-sharing features, demonstrating a need to educate the general public on the subtleties of our complex healthcare system.

The authors acknowledged a key limitation in the study: the random selection of a customer service representative when the shopper called. It’s possible that calling at a different time could have produced a representative who was familiar with the ACA regulations, but the authors wanted the mystery shopper’s experience to match that of a typical consumer, so she only called each insurer once.

“Customers need help in choosing plans that are right for their personal health histories and economic status,” the authors wrote. “Health insurance customer service representatives can be a good resource in guiding consumers to make individualized plan choices, as long as the representatives themselves are informed of plan details and able to communicate them effectively to customers.”