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California probes Obamacare doctor networks at Anthem and Blue Shield

Laws and LegislationInsuranceConsumersAffordable Care Act (Obamacare)
Two large California health insurers face state scrutiny over narrow networks, patient access
Anthem Blue Cross, Blue Shield of California lead the state on complaints about provider issues

California regulators are investigating whether Anthem Blue Cross and Blue Shield of California have violated state law in connection to patients struggling to find doctors under Obamacare.

Officials at the California Department of Managed Health Care said they are looking into whether consumers were misled by inaccurate provider lists and the difficulty some patients are still having at locating a physician in narrower networks statewide.

"We began our review based on a pattern of complaints that came to our help center regarding provider access," agency spokeswoman Marta Green told The Times. "Our preliminary investigation gave us good cause to believe there are violations of the law."

Green said the department expects to wrap up its investigation within 60 days and then send its findings to the two companies. The insurers will then have 45 days to respond.

The disclosure of a state investigation raises the stakes for one of the biggest problems plaguing the initial rollout of the Affordable Care Act.

Both Anthem and Blue Shield have acknowledged that mistakes have been made with respect to their networks and some confusion was inevitable during such a massive overhaul. The two insurers say they have tried to contact doctors repeatedly to confirm their network status, and they have both added more providers since January.

Last week, the president of Anthem Blue Cross defended the use of limited networks as a way to get lower rates from medical providers and pass along the savings to consumers.

A poll this year by the Kaiser Family Foundation found that 54% of people who are uninsured or buy their own coverage would rather have a health plan that costs less, even with a limited range of providers. However, support fell to 35% when people were told they might not be able to use their regular doctor and hospital.

Many consumers have vented for months about the smaller networks that insurers stitched together for the start of Obamacare coverage. The complaints have touched on a number of different issues.

First, insurers and California's health exchange confused people by publishing erroneous lists of network providers. Consumers often relied on that information to choose which health plan to buy.

Then patients got conflicting answers from insurers and doctor's offices as to whether a physician was accepting their plan.

In other cases, patients received treatment only to find out later that their insurer considered the provider out of network and wouldn't cover the bill.

"Anthem and Blue Shield have led the pack on these network and provider issues," Green said.

Anthem, a unit of industry giant WellPoint Inc., was the subject of 115 provider-related complaints from January to early June, according to state figures. Blue Shield was second with 97 complaints related to physician access.

Anthem said it will help customers find a doctor if they're experiencing a problem.

"Anthem Blue Cross continually works to improve the accuracy of our provider directory," spokesman Darrel Ng said. "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."

Anthem said it has added more than 3,800 medical providers to its statewide exchange network since January.

Blue Shield said its PPO network for individual coverage has grown to include 64% of physicians and more than 82% of hospitals on its standard PPO roster.

"We are redoubling our efforts to inform physicians and our customers as to what the network makeup is," said Steve Shivinsky, a Blue Shield spokesman. "If some corrective action is necessary as a result of the state survey, we will do that."

State officials want to release the results of the investigation before open enrollment starts again in November. Part of the inquiry includes making calls to network doctors to verify their participation in a health plan and check whether they're taking new patients.

In the first enrollment period, 1.4 million people signed up for private health insurance through the Covered California exchange. Anthem and Blue Shield were the top two insurers by enrollment, grabbing nearly 60% of that market.

Some exchange customers have started to take their network complaints to court. Last month, two San Francisco residents sued Blue Shield in state court, accusing the company of misrepresenting that their policies would cover the full network.

Blue Shield said “we believe enrollees should be as informed as possible about the products they select” and declined further comment on the case.

Copyright © 2014, Los Angeles Times
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Laws and LegislationInsuranceConsumersAffordable Care Act (Obamacare)
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