Patients Caught in Feuds
When consumers enroll in a medical plan, they should feel confident they will have access to all the doctors and hospitals participating in the plan.
But the world of “should” too often is not the world of reality. And patients may panic when they get a letter saying that surgery has been postponed because the health plan is fighting about fees with the hospital or that the doctor has dropped out of the health plan.
Someone who is worrying about health problems suddenly has a new fear: Can he or she get the needed medical care, and will the bills be covered by health insurance?
The situation is particularly complicated in California, where there is another layer of potential confusion between the patient and health plan. Most people get their care from medical groups, which are partnerships or associations of doctors who have banded together to deal with patients, hospitals and health insurers.
Many things can go wrong. Medical groups have contract disputes with health insurance plans. Groups sometimes cancel their contracts or get fired by the health plan. Individual doctors who were in a health plan network stop accepting patients from that health plan. Or the plan fires them. Or a medical group runs into financial difficulties and goes broke.
Consumers need to know how to deal with all these confusing possibilities.
There are more than 300 medical groups operating in California and as many as 30 health plans, creating the potential for hundreds or even thousands of different contracts, according to Walter Zelman, head of the California Assn of Health Plans.
The financial collapse of a medical group is frightening for consumers. But they are protected--the health plan has the duty of finding a new doctor for these people and guaranteeing uninterrupted medical care.
“The most difficult situation for any health plan is when a provider group ceases to operate,” said Michael Chee, a spokesman for Blue Cross of California. “We’ve got to get the plan members placed somewhere else as quickly as possible,” he said. Usually, he said, there is some warning that a medical group may be having problems, and preparations are made for transitions.
When the event occurs, Blue Cross has a group of specially trained transition nurses who will work with affected patients, helping find new doctors and assure that patient care works smoothly, he said.
Health plans have the same legal obligations to customers when an individual doctor leaves. The health plan might drop the doctor because it’s dissatisfied over performance. Or the doctor might not like the plan and decide to stop accepting its patients.
Aetna tries to give its members 90 days’ notice if a doctor is quitting an Aetna network, according to Rachelle Cunningham, an Aetna spokeswoman. The company also tries to find another doctor whose office is near the patient’s home, and case managers work with the patient on the transition to the new doctor.
The biggest problems--the ones touching the most patients--typically occur when a health plan is having a major contract dispute with a big group of doctors or hospitals.
When these fights occur, there is a sudden spike in the number of calls from worried consumers to the state’s Department of Managed Health Care, which regulates HMOs.
“It’s a very big deal,” said Daniel Zingale, the director of the department. Zingale has been able to intervene, using his powers as a regulator under California law, which has some of the most powerful patient protections of any state.
In these disputes, the feuding parties are arguing about money, with the health plan saying the doctors and hospitals want too much, and physicians and hospitals saying the health insurer is stingy in reimbursements. They tell patients that services may be postponed while they argue. This is where Zingale uses his authority under state law as a regulator to force them to continue care.
When Blue Cross of California and the Sutter Health system battled last year over fees for hospital stays, some patients were told that their scheduled procedures had been canceled and that they could not have access to a Sutter hospital.
A woman whose 9-year-old son who needed surgery to remove a blood clot on in his brain was told that the delicate and expensive operation would not be covered by insurance because of the contract fight. Zingale’s department stepped in, and the surgery went forward, with the full cost covered by the insurance.
“A lot of patients are left confused and didn’t know they should call us,” he said.
Here are the basic rules for consumers who are members of HMOs regulated by the state. Continuity of coverage is guaranteed during an acute medical condition. People who need imminent surgery or have a vital course of treatment underway are assured they will get into the operating room. Those undergoing chemotherapy for cancer are ensured the treatments. Patients with AIDS are guaranteed continued access to the vital drugs and therapies that will keep them alive. Examples: A patient with congestive heart failure can be assured that his bypass operation will go forward as scheduled. And a woman in the second or third trimester of pregnancy can keep going to her current doctor even if his medical group canceled its contract with the HMO or other health plan.
By state law, the insurance coverage must be maintained, and the medical group and the insurer can later settle the issue of who pays what. Meanwhile, the consumer doesn’t have to foot the bill.
Zingale has also intervened in cases in which medical groups simply disappear as providers, falling into bankruptcy.
“We’ve literally had situations where the parking lot of the medical group is filled with patients who came for appointments, and the door is locked, with a notice posted that the group is bankrupt,” he said. The state talks to other HMOs about picking up the customers.
Sometimes, a health plan may collapse financially. In the past year, the state took over the responsibilities of three California HMOs, which weren’t paying doctors or hospitals on a timely basis. The state regulators parceled out the accounts, assigning the patients to other health plans in their communities.
The Department of Managed Health Care help line for those caught in continuity of care disputes, as well as other HMO issues, is (888) 466-2219 (HMO-2219). The Web site is https://www.hmohelp.ca.gov. Consumers should appeal first to their health plan, and if they get no satisfaction, then go to the state.
Another tip from the department: Consumers should get copies of their medical records and keep a set at home. They are entitled to get this information from the doctor’s office, usually at a modest fee for the cost of copying the pages.
By getting a personal copy of their records, patients can avoid the troubles that befell the customers of the KPC medical group, which shut down last year, leaving all the patient files locked away in a warehouse. After months of negotiations, the state persuaded HMOs that had dealt with KPC to retrieve the records and get them to the patients.
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Bob Rosenblatt welcomes questions, suggestions and tips about coping with the changing world of health care. Contact him by writing Bob Rosenblatt, Health, Los Angeles Times, Times Mirror Square, Los Angeles, CA 90053, or by e-mailing bob.rosenblatt@latimes.com. Health Dollars & Sense runs the second Monday of each month.
