Frustration and legal challenges over the network of doctors and hospitals for
Limiting the number of medical providers was part of an effort by insurers to hold down premiums. 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.
"I thought I had done everything right, and it's been awful," said Jean Buchanan, 56. The Fullerton resident found herself stuck with an $8,000 bill for cancer treatment after receiving conflicting information on whether it was covered.
"How am I going to come up with that much money?"
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 Mark Morgan, president of Anthem Blue Cross, a unit of industry giant WellPoint Inc. "We found in convincing numbers that people value price above all else."
But regulators, lawmakers and consumer advocates are pushing back to ensure patients know what they're giving up in return for lower rates — and don't run into unnecessary roadblocks to care.
This month, the California Department of Managed Health Care began investigating whether two major insurers, Anthem Blue Cross and Blue Shield of California, are violating state law related to inaccurate provider lists and offering timely access to treatment.
Regulators say customers of those two companies, which account for nearly 60% of Covered California's enrollment of 1.4 million people, have complained the most about provider-related issues.
Consider Buchanan, who lost her previous coverage when her insurer dropped out of the individual market last year. She was diagnosed with breast cancer in July, so she opted last fall for a Platinum plan, the highest level of benefits on the state exchange, from Blue Shield.
Buchanan 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. She initially canceled the surgery, but her family and friends told her she shouldn't risk waiting.
Buchanan is paying $200 a month on her $8,000 surgery bill. UC Irvine said there's been considerable confusion among Blue Shield customers with exchange plans.
Tom DiCioccio, 64, of Oceanside faced a similar predicament after getting diagnosed with cancer in his lymph nodes. The retired shoe designer owes nearly $20,000 for his cancer surgery this year after Blue Shield switched him into a policy with fewer providers.
The insurer covered his care at
After being contacted by The Times, Blue Shield reversed itself and told DiCioccio it would take care of his bills. The San Francisco insurer said DiCioccio shouldn't be penalized for going out of network because he was already undergoing treatment before his policy changed.
DiCioccio was unimpressed. "What about everyone else? There are so many other people like me," he said.
Blue Shield stood by its handling of Buchanan's case because it said she was advised UC Irvine was out of network.
"People need to be very diligent in deciding where to go," company spokesman Steve Shivinsky said. "We are trying to do our part to educate people, but it's a big task when the market has been totally turned upside down."
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.
Anthem has added more than 3,800 providers to its exchange network since January, and Blue Shield said its preferred provider organization network for individual coverage had grown to include 64% of physicians on its regular roster.
Nationwide, about half of all exchange plans feature narrow networks, according to consulting firm McKinsey & Co., which has closely tracked the new insurance market. Those 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.
Los Angeles pediatrician Danelle Fisher 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.
Fisher decided she could not accept Covered California insurance but thought other Blue Shield patients would not be affected — a common misperception among doctors and patients. Blue Shield's new terms also applied to patients with individual policies outside the exchange.
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. Samantha Cowart of Fallbrook sued her insurer June 20 in Los Angeles County Superior Court, accusing Anthem of misleading customers. Like nearly 1 million Californians, Cowart 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, Cowart incurred several thousand dollars in medical bills that Anthem wouldn't cover, according to her Pasadena attorney, Scott Glovsky.
Anthem declined to comment on the pending litigation.
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.
Accurate information can be crucial because so many doctors now are available in just one health plan. New data show that 57% of doctors in Covered California are in a single health plan, compared with 28% in the individual market a year earlier, according to consulting firm Cattaneo & Stroud Inc.
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.
"Narrow networks aren't going away, and we don't need access to every doctor," said Anthony Wright, executive director of Health Access, a consumer advocacy group. "But patients should have certain expectations and guarantees."