Healthy Choices

Anthem, Blue Shield fined $600,000 for faulty doctor directories

This April 8, 2015, file photo shows the headquarters building of Blue Shield of California in San Francisco.
This April 8, 2015, file photo shows the headquarters building of Blue Shield of California in San Francisco. AP

As part of the bumpy rollout of Obamacare in California, two major insurers – Anthem and Blue Shield – were issued $600,000 in fines Tuesday because they provided inaccurate doctor directories that resulted in costly overcharges for some patients.

The fines are based on statewide surveys in June 2014 that found more than 25 percent of Anthem Blue Cross and Blue Shield of California’s online doctor listings were faulty, either because the physicians weren’t in the location listed or weren’t offering plans as cited.

“Those surveys found inaccuracies that limited access to care and resulted in an unacceptable consumer experience,” said Rodger Butler, spokesman for the state Department of Managed Health Care.

The surveys were prompted by numerous complaints from consumers who had trouble last year finding in-network Anthem or Blue Shield physicians in their area, either through their Covered California plan or an individual plan. Many patients went to doctors they mistakenly believed were part of their plan’s network, only to discover they were being charged excess fees for out-of-network doctors.

“Now that people have choices and can shop between plans, provider directories take on a much more important role,” said Anthony Wright, executive director of Health Access California, a health care consumer advocacy group. “We don’t allow grocery stores to sell products with inaccurate food labeling. ... We can’t have a functioning insurance market if consumers don’t know what they are buying.”

The fines are a pittance compared to the two insurers’ bigger cost: millions in reimbursements to patients who were charged out-of-network costs because of the inaccurate listings. Blue Shield has already paid more than $38 million in refunds to affected patients. Anthem is expected to issue reimbursements as part of a class-action lawsuit pending in Los Angeles Superior Court, but no settlement date or payment amounts have been given.

The fines come as the country’s third annual open enrollment under the Affordable Care Act gets underway. Consumers can re-enroll or choose a health care plan from now through Jan. 31.

“Inaccuracy of provider directories is an age-old problem, and the fines are an incentive to clean things up,” said Betsy Imholz, special projects director for the nonprofit Consumers Union in San Francisco. Imholz said the best outcome would be a standardized provider directory combining all health plans so consumers could easily see which plans cover their personal doctors.

Both insurance companies noted that major upheaval in the insurance marketplace due to implementation of the Affordable Care Act contributed to the problems.

“There was a pretty steep learning curve for all involved with new rules, new regulations and a brand-new marketplace,” said Blue Shield spokesman Matthew Yi.

But Yi said Blue Shield has been “diligent” in addressing the problems and has been training providers, revamping its directories and paying millions of dollars in reimbursements to patients hit with high costs for using out-of-network doctors.

Similarly, despite continual efforts in a “time of unprecedented change,” Anthem’s doctor directories “inadvertently listed some providers,” said spokesman Darrel Ng. Not all of Anthem’s doctors participate in all of its plans, and the online directories didn’t catch every instance in which there were differences, he said. Some doctors were available to CalPERS members, for example, but not available to Covered California plans.

He added that Anthem has spent more than $4 million improving its provider directory “to make it more user-friendly and to improve the accuracy of the data.”

The outcry over inaccurate provider directories led to SB 137, a bill by state Sen. Ed Hernandez, D-West Covina, that requires all California insurers to update their online directories weekly and printed directories quarterly. Physicians are required to verify changes to their listings and can be denied insurance payments if they don’t comply in a timely fashion. The bill, effective July 1, 2016, was signed by Gov. Jerry Brown last month.

Consumers who believe they should be reimbursed for out-of-network fees in 2014 should contact their insurer, using the number on the back of their member card. If not satisfied, they can file a complaint with the DMHC at HealthHelp.ca.gov or 888-466-2219.

Editor’s note: This story was changed Nov. 4 to correct the total amount of fines against Anthem Blue Cross and Blue Shield of California.

Claudia Buck: 916-321-1968, @Claudia_Buck

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