Californians report roadblocks in new era of health care

07/08/2014 12:00 AM

07/08/2014 9:36 AM

John Aiello was thumbing through the directory of physicians provided by his insurance company when he came upon a surgeon with a familiar name. Could this be the specialist who treated his ailing father years ago in San Francisco?

“I know the doctors there very well,” said Aiello, 50, a writer who lives in Mount Shasta.

Turns out it was the same surgeon, but he had moved out of state long before. Last year, he died after battling an illness of his own.

Inaccurate provider lists are among the challenges facing customers as many transition from the ranks of the uninsured under the federal health care overhaul. Covered California, the nation’s leading state exchange, alone has signed up 1.4 million people through the Affordable Care Act.

More than 1,800 complaints about the process were submitted to state regulators through June 8. Customers have complained that they haven’t received their identification cards and enrollment packets. They’ve said they had trouble navigating narrow networks to find a doctor who will take their coverage.

The complaints resonating most with state regulators, however, have come from those reporting that a provider won’t accept their plan or that directories of doctors are inaccurate.

In response, the California Department of Managed Health Care is investigating whether Anthem Blue Cross and Blue Shield of California violated state law, which requires insurers to have enough providers and to maintain an accurate list of participating doctors.

An initial review has given officials good cause to suspect the plans are violating the law, said Marta Green, an agency spokeswoman. Findings of the roughly two-month investigation into the exchange’s largest insurers will be sent to the plans, which will then have 45 days to respond.

Representatives for health insurance companies said they have been working diligently to tackle the issues. In some cases, they found that doctors were in an insurer’s Covered California network, but that office assistants answering the telephone provided incorrect information about their status. Insurers also note that their contracts generally require provider groups to notify them when doctors move or retire.

Steve Shivinsky, a spokesman for Blue Shield, said in a statement that the company has submitted to investigators all of the requested files.

“Blue Shield continues to take action to address any issues causing confusion in the marketplace with our providers and customers,” Shivinsky said.

A representative for Anthem Blue Cross said in a statement that officials there regularly work to improve the accuracy of their provider lists.

“In the process of updating our provider database earlier in the year, we found that while the vast majority of the listings were correct, there were some providers inadvertently listed,” said the spokesman, Darrel Ng.

Overall, he said the firm has added more than 3,800 doctors to its statewide exchange network since Jan. 1. Some providers who were inaccurately listed later decided to join the network, he said, recommending that those with problems call the customer service line on the back of their identification cards.

He said Anthem Blue Cross has put considerable effort into educating doctors and other health care providers about their standing with the insurer.

“Anthem is manually calling thousands of providers in our exchange network to verbally notify them of their status, with a priority placed on the regions with a higher number of inquiries,” he said.

The state exchange says it has been working with regulators, and plans to evaluate networks and respond quickly to consumer concerns. It also has referred complaints about provider access to regulators when appropriate, spokeswoman Anne Gonzales said.

“We continue to be diligent in responding to enrollees having any trouble accessing care, so we can find swift resolutions,” she said.

In the meantime, problems involving provider lists continue to surface.

The Humboldt-Del Norte County Medical Society reviewed one insurer’s provider lists and reported late last month that just one-third of area doctors were accurately reflected. Many were not seeing patients with that insurance coverage, had moved from the area, or had retired, according to the California Medical Association, of which the society is a subsidiary.

The countywide review came after the medical association surveyed physicians and determined that 80 percent were confused about their participation status. It followed up with a one-page letter to members.

“Health plans often use intentionally vague or confusing contracting practices, which result in consumer confusion and frustration, as physicians often do not know that they are listed as participating in certain networks,” the June 25 letter stated. “With roughly 1.4 million Californians newly enrolled in Covered California products since January, it has been difficult for both physicians and patients to identify who is in and who is out of the narrow provider networks.”

Denise Warmerdam, 52, of Lodi signed up for an insurance policy that mirrors one on the state exchange. Among the motivations was that her doctor of 18 years appeared on the provider list – and was on the list as recently as June 27.

In April, Warmerdam saw her doctor. She said she was told she needed to have a hysterectomy quickly, but that the doctor did not accept her insurance. Thankfully, she said, the hospital where the surgery occurred was covered by her plan.

“We made the decision to continue with our doctor and ‘cash pay’ because of the history and relationship with her,” Warmerdam said. But “we really feel like this was false advertising.”

Warmerdam’s insurance agent said she would not be able to change the policy until the enrollment period that begins next year.

Enrollment experts and health insurance agents stress that the issues identified involve only a fraction of those insured. Todd A. Larner, an agent certified to provide plans through the exchange, said his firm has not seen any clients have difficulty with the “skinny” networks.

Larner, of Groundwork Insurance Services in Burbank, said that the company from the beginning asked clients to let them know about their families’ “must-have” physicians and hospitals.

“We did find that, oftentimes, a hospital or physician listed as taking a particular carrier’s plan in the carrier’s literature differed from the hospital (or) physician’s understanding of whether they were accepting the carrier’s plans,” he said.

In many cases the hospital or doctor would believe they were “in” with a particular carrier and later found out they were not. “This was an extreme challenge in the beginning of the year as carriers were including and excluding physicians/hospitals up until the last minute,” he said.

Larner and other agents said they hope the insurers and exchange are able to improve their systems. Specifically, he said he hopes that carriers with narrow networks will have enough of a positive experience this year to widen them going into 2015.

Aiello, who came across the deceased surgeon in a directory, said he learned in May that his new policy doesn’t cover his doctor of nearly 25 years.

“I thought he was in-network because he shows up (on the insurer’s list) as being in-network,” Aiello said, calling the episode an unfortunate learning experience. “I am going to triple-check everything I do.”

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