Confusion over doctor lists is costly for Obamacare enrollees in state

Frustration and legal challenges over the network of doctors and hospitals for Obamacare patients have marred an otherwise successful rollout of the federal healthcare law in California. Limiting the number of medical providers was part of an effort by insurers to hold down premiums. 

Covered California had sought to address much of this by promising an online listing of exchange providers so consumers could search for their favorite doctor or hospital before picking out an Obamacare policy. The exchange’s provider directory wasn’t ready when enrollment began in October, and it was later killed because of inaccuracies.

  • But confusion over the new plans has led to unforeseen medical bills for some patients and prompted a state investigation. More complaints are surfacing as patients start to use their new coverage bought through Covered California, the state’s health insurance exchange.

A Fullerton resident found herself stuck with an $8,000 bill for cancer treatment after receiving conflicting information on whether it was covered. The Fullerton resident, who lost her previous coverage when her insurer dropped out of the individual market last year. She enrolled in a Platinum plan, the highest level of benefits on the state exchange, from Blue Shield.

She started treatment at UC Irvine Medical Center in the fall, and her oncologist there took her new Blue Shield insurance in January and February. Then the day before her lumpectomy, UC Irvine called to say her insurance wasn’t accepted after all.

UC Irvine said there’s been considerable confusion among Blue Shield customers with exchange plan. Blue Shield stood by its handling of the case because it said she was advised UC Irvine was out of net

An Oceanside resident faced a similar predicament after getting diagnosed with cancer in his lymph nodes. The insurer covered his care at Cedars-Sinai Medical Center on his prior plan, and he said Blue Shield never advised him of any major changes. Like many consumers, he said it was nearly impossible to get information from the company’s call center or website.

  • A Los Angeles pediatrician said she couldn’t afford the 30% pay cut offered by Blue Shield. She would have received $68 instead of $97 for a routine office visit for a patient with a PPO policy. She decided not accept Covered California insurance but thought other Blue Shield patients would not be affected.

This is a common misperception among doctors and patients. Blue Shield’s new terms also applied to patients with individual policies outside the exchange.

In all, customers of Blue Shield in Covered California have filed 590 complaints with the state this year through early June, and 97 of those gripes are about the insurer’s networks.

Even more complaints have been lodged against Anthem Blue Cross, the state’s largest for-profit insurer and the leading company by enrollment in Covered California. The insurer has 848 complaints, including 115 related to provider issues.

Both companies have emphasized that complaints represent a small percentage of enrollment. Anthem and Blue Shield have contacted medical providers repeatedly to clear up confusion, and they have expanded their networks in recent months.

  • Narrow networks aren’t going away, and we don’t need access to every doctor. But patients should have certain expectations and guarantees. Insurers insist that pruning the network of doctors is a crucial cost-cutting measure and a major reason that so many Californians could find affordable coverage in the health law’s first year. “These narrow networks are making a huge difference in terms of affordability,” said the president of Anthem Blue Cross, a unit of industry giant WellPoint Inc. “We found in convincing numbers that people value price above all else.”

Nationwide, about half of all exchange plans feature narrow networks, according to consulting firm McKinsey & Co., which has closely tracked the new insurance market.

  • Narrow network plans cost up to 17% less on average than plans with broad networks. In forming tighter networks, insurers tried to persuade doctors and hospitals to accept less money in exchange for a higher volume of Obamacare patients.

Meantime, some consumers are taking their network gripes to court. Last month, two San Francisco residents sued Blue Shield in state court, accusing the insurer of misrepresenting that their policies would cover the full network.

The latest case involves Anthem. A Fallbrook sued her insurer June 20 in Los Angeles County Superior Court, accusing Anthem of misleading customers. Like nearly 1 million Californians, she had a policy that was canceled last fall because it didn’t comply with requirements of the Affordable Care Act.

To ease her transition, Anthem enrolled her in an exclusive provider organization plan that limits her access to out-of-network care even more than the PPO plan she had for 16 years. But Anthem sent her an insurance card in February labeling her coverage as a PPO. As a result, she incurred several thousand dollars in medical bills that Anthem wouldn’t cover, according to her attorney.

Exchange officials said it’s too early to tell what effect, if any, the state investigation or pending legislation may have on next year’s networks and rates. State lawmakers are considering two bills that would increase oversight of these network issues and require insurers to foot the bill for out-of-network care if regular providers aren’t available.

*Modified from a article

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