Most major health insurers in California do a poor job of paying claims and providing customer service for members in preferred provider organization plans, according to a new state survey.
The evaluation by the California Department of Insurance comes as many workers assess their healthcare options this month before enrolling for another year of insurance benefits through PPO plans that serve 2.5 million people statewide.
In the quality report card, Anthem Blue Cross, Blue Shield of California, Health Net Inc., UnitedHealthcare and Cigna Corp. received the lowest possible ratings — poor — for customer service. Aetna Inc. earned a slightly better rating of fair.
Most of those insurers also garnered marks of fair for the ease and speed with which members see doctors and get medical care. UnitedHealthcare earned a grade of good.
No insurer received the top overall rating: excellent.
The insurers said they welcomed the scrutiny even as they defended their own efforts to improve customer satisfaction and streamline care.
But California Insurance Commissioner Steve Poizner called the findings “atrocious,” saying insurers “must step up and improve the quality” of their healthcare services in a marketplace that generates $17 billion a year in revenue.
“This is hopefully a wake-up call for insurance companies,” Poizner said Thursday. “They are simply underperforming. People should be concerned.”
Healthcare advocates said the new PPO study would fill a void for consumers.
“This is especially important at this time, during open-enrollment period, when people evaluate their coverage for the new year,” said Anthony Wright, executive director of the nonprofit consumer advocate Health Access California.
“With the PPOs getting low marks, they should see this as an opportunity to improve and to compete on customer service and satisfaction,” Wright said.
The study also evaluated whether PPO members received adequate medical care through cancer screenings, cholesterol testing and other services. It found that Anthem Blue Cross, Blue Shield and Health Net did a fair job of meeting quality standards spelled out by national experts. Aetna, Cigna and UnitedHealthcare did a good job of meeting those criteria.
The report card, in its second year, is patterned after a similar review of health maintenance organizations conducted by the state Office of the Patient Advocate.
The most recent HMO study, in February, gave most of the companies high marks for customer satisfaction but said they needed to improve their screenings for cancer and other ailments. HMOs serve nearly 21 million people in the state.
Anthem, the state’s largest PPO provider, said it aggressively analyzes data on claims, pharmacy services and health risks to notify members of gaps and make clinical recommendations.
The Woodland Hills insurer said it has sought to improve patient education about diabetes, one of the healthcare categories studied by the state.
Anthem also pointed out that its PPO plans performed well on several care measures in the study, including breast cancer screenings and the treatment of children with upper respiratory infections.
“We continue to enhance clinical and nonclinical programs to improve … member satisfaction,” the company said.
UnitedHealthcare said it partners with medical offices to free doctors from administrative burdens so they can spend more time with patients. The insurer said that physicians now can process their claims almost immediately online, and nearly all such claims are handled within 10 days.
UnitedHealthcare received one of the best overall ratings of the six major PPO companies, earning scores of good for medical care and timely access to doctors.
“We are pleased that the latest PPO report card reflects our commitment to providing quality care to our members,” the company said.
Cigna said it offers round-the-clock customer service and online tools that give customers instant access to cost and quality information. The insurer said it also has simplified its explanations of benefits to make them easier to understand.
“Cigna is making tremendous strides in customer service, and we are committed to continuous improvement,” the company said. “We believe that these and other service initiatives will improve our customer service scores next year.”
Health Net and Aetna said the findings would help them better tailor their services and provide more efficient access to care.
Blue Shield did not comment on the study.