Some doctors opt out of Covered California plans

April 28--Barbara Hollister of Thousand Oaks was uninsured for 10 years. The first time she tried to use the health plan bought through Covered California, it seemed nothing had changed.

Her primary care doctor opted not to accept the plan, she said. Instead of a $40 copay, the 61-year-old part-time mail clerk was told she would have to pay almost five times that amount.

The math led her to the next decision.

"I said 'I have to find another doctor,'" she said.

Many Ventura County doctors say low reimbursement rates have convinced them not to participate in insurance plans created by President Barack Obama's reform program. Other physicians who thought they were part of plans bought through Covered California are learning they are not.

It means some patients end up paying for appointments in cash and asking for reimbursement from their insurance companies.

Or they try to find new doctors.

Before she bought her Blue Shield policy for premiums of $141.27 a month, Hollister made sure her doctor was covered. But she was told the doctor decided to go out of network because the insurer had rejected another patient's claim.

"She said 'We can't live on $40 a patient,' " said Hollister's sister, Kathy, referring to the copay.

The Hollisters said they were asked to pay and were given a form to send to Blue Shield to get at least some of the money back.

Confusion over physician coverage was a constant during a six-month enrollment period that saw nearly 1.4 million state residents sign up for plans through Covered California. An online tool designed to help consumers find doctors covered by specific plans was removed from Covered California's website because of inaccuracies.

Anthem Blue Cross wrote letters to doctors -- nearly 1,000, according to California Medical Association officials -- telling them they were incorrectly listed by the insurance company as being in the network.

Coverage confusion is magnified in Ventura County because the vast majority of insurance plans are sold by Anthem Blue Cross and Blue Shield of California, said Jodi Black, senior director of the medical association's Center for Economic Services.

Both companies offered smaller doctor networks in individual and family policies compared to some of their plans outside of the exchange, she said.

Kaiser Permanente also provides Covered California plans in Ventura County. Their physician networks were unchanged in the new plans.

Some private practice doctors say they don't know if they're part of networks or not.

"Physicians aren't getting a clear message," said Mary Carr, executive director of the Ventura County Medical Association. "Until they get that clarified, many are not going to see patients."

Insurers said they're addressing problems by notifying doctors who are participating in their networks. Anthem Blue Cross spokesman Darrel Ng said letters have been sent not only to doctors but to every location where a physician practices.

"A lot of the confusion has been strained out," Ng said, refuting the implication that Anthem's network of doctors is dwindling. Nearly 2,000 doctors have been added to the plans linked to Covered California so far this year.

Many doctors who received letters from Anthem saying they were incorrectly listed as participating in a plan later signed up to the network, Ng said.

Lindy Wagner, spokeswoman for Blue Shield of California, said the insurer offered doctors a trade: A way to tap into the new wave of insured patients created by federal reform in exchange for payment reduced by as much as 30 percent. She said the rate cut allowed the insurance company to keep premiums affordable in Covered California plans.

The rate cut is a big reason some doctors are opting out.

"They basically wanted to cut our fees by 30 percent to see patients," said Dr. Jeffrey Brackett, a Ventura cardiologist, referring to Blue Shield. "We said we can't do that."

Brackett retains hope insurers will expand their networks once they're convinced the Covered California plans are profitable.

Covered California officials said they take the complaints seriously and are working with the plans, doctors and consumers to address problems. They're referring some people with unresolved issues to state regulators and are considering strategies aimed at improving the accuracy of the physician listings kept by insurers.

As it stands now, people can likely still see doctors who are out-of-network. But they may face increased out-of-pocket payments.

Some doctors work out deals with their patients. Others ask for cash up front and instruct patients to seek partial reimbursement from the insurance company. Some safety net clinics that accept all comers expect their patient numbers to increase.

Dr. Timothy McNicoll, a family practice doctor in Simi Valley, was not offered a contract in Covered California. Which is fine. He didn't want one.

"I didn't think I could run an office on the rates they offered. I would have declined," said the Simi Valley family practitioner.

Darilynn Chierichetti has been McNicoll's patient for more than 20 years and praises him. She'll pay cash to see him but thinks she may also need a doctor covered by the Anthem Blue Cross plan she purchased through Covered California.

The 59-year-old Simi resident considered a half-dozen different doctors. Three doctors said they were incorrectly listed in Anthem's network. Another wasn't taking new patients. Two doctors' phone numbers listed on Anthem's site were disconnected.

She's still looking.

"They're promising you all these doctors," she said, "and it's not true."

--

More info

People scrambling to figure out if their doctors are covered, should check their insurance company's website. They should also call their doctors.

Anthem Blue Cross: www.anthem.com/ca and click on "find a doctor." Or call the number on the back of your insurance card.

Blue Shield of California: www.blueshieldca.com and click "find a provider." Or call the number on the back of your insurance card.

Kaiser Permanente: http://bit.ly/1gaMhkR. Pick a region and hit "go." Or call 1-800-488-3590.

Covered California: Call 1-800-300-1506. For information on an appeal to switch plans, go to http://bit.ly/1pHMPDb.

California Department of Managed Health Care: 1-888-466-2219.

___

(c)2014 Ventura County Star (Camarillo, Calif.)

Visit Ventura County Star (Camarillo, Calif.) at www.vcstar.com

Distributed by MCT Information Services