Editorial: Stop the guessing game over which doctors are in-network


One of the loudest complaints about the policies sold through Covered California, the state’s new health insurance exchange, is that they provide access to far fewer doctors than promised. On Wednesday, state regulators finally confirmed and quantified the problem with respect to two leading insurers, Anthem Blue Cross and Blue Shield of California. Yet as is typical in the healthcare industry, it’s not entirely clear who’s responsible, nor is there an easy fix.

Earlier this year, the state Department of Managed Health Care surveyed a representative sample of the doctors that Anthem and Blue Shield listed in their provider networks online. The department discovered that more than 25% of the entries on each insurer’s list appeared to be wrong, with the doctors not in the locations listed or claiming not to take Covered California patients. The numbers reinforce the suspicion that some doctors are avoiding patients with Covered California plans because insurers pay so little to treat them.

The insurers insist that the situation isn’t as bad as it looks. The vast majority of doctors’ offices contacted by the state were, in fact, in Anthem’s or Blue Shield’s networks, even if they said they weren’t. That’s not much comfort to patients who are turned away, however. More encouragingly, both insurers have contacted their networks to remind doctors and their staffs of what their contracts require. This outreach has evidently helped — state officials say that the number of complaints has dropped. Nevertheless, they worry about the problems flaring up again as the new open enrollment period brings more people into Covered California policies.


And flare up they will, because networks are in constant flux. Blue Shield reports that it receives thousands of notices every month about doctors retiring, changing locations, switching group practices or turning down new patients. That’s why signing up for a plan is a little bit like buying a pig in a poke. Insurers are obligated to maintain an adequate network of providers, but they can’t stop individual doctors from dropping out.

Patients should not have to guess before they walk in whether a doctor is in their network. And doctors should not be able to plead ignorance about which networks they’re in. At the very least, state officials need to do more surveys of provider networks, pressuring insurers to keep their online directories up to date and their providers on board. What the industry really should do, though, is develop a way for doctors to update insurance companies electronically about changes in their practices, just as it’s working to let providers exchange digital health records. At this point in the 21st century, there’s no excuse for doctors and insurers not to be in sync.

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