Provider network controversies from the first Affordable Care Act enrollment are coming back to bite two large Blues in the second open enrollment, while raising questions about responsibility for consumer confusion.
California's Department of Managed Health Care is mulling sanctions for Anthem Blue Cross of California and Blue Shield of California, after Department surveys of the insurers' public exchange provider networks found more than a few physicians listed as in-network who said that they actually weren't accepting patients on the plans.
The Department of Managed Health Care (DMHC) believes that both insurers have not been in full compliance with four provisions of California's management care law, the Knox-Keene Act.
According to the DMHC's investigations, the two insurers' Covered California plans "informed enrollees that numerous physicians" were available "when they were not," published misleading information to induce enrollment, promulgated inaccuracies in provider information, and failed to notify regulators about a 10 percent or greater change in providers after initial reviews.
This past spring and summer, after a number of consumer complaints, the DMHC conducted telephone surveys of a random sample of about 3,000 physicians listed in each of the insurers' exchange and off-exchange individual plans, asking whether they accepted patients insured under the plans.
In Anthem Blue Cross plans, the DMHC found that 12.5 percent of the doctors listed in the online directory were not actually at the specified location. Almost the same proportion of the sample, 12.8 percent, said they were not accepting patients enrolled in Anthem's Covered California plans. And in a study of Anthem's exchange plan primary care network in Sacramento County, the DMHC found a change of more than 10 percent of available providers after its original 2012 regulatory filings.
In Blue Shield of California's plans, the DMHC found that 18 percent of the doctors in the directory were not at the location as listed, and almost 9 percent of the physicians surveyed said they were not accepting Blue Shield exchange plan members. The Department also found changes of greater than 10 percent in the insurer's Sacramento County primary care network after the 2012 filing.
These "deficiencies" have been referred to the DMHC's Office of Enforcement for additional corrective action or other remedies, and regulators plan to conduct a follow-up survey in six months. The telephone surveys asking physicians if they accept the insurers Covered California plans were "designed to duplicate the consumer experience," regulators wrote in the report.
Anthem and Blue Shield, though, both argue that the methodology is flawed and suggest that the origins of consumer confusion -- members being rejected by a doctor listed as in-network -- may actually stem from providers not understanding their contractual obligations to accept the patients from the health plans.
Anthem Blue Cross noted that "the contractual status of a provider is a greater indicator of availability than a phone survey, and that its contracted providers are under no contractual or ethical obligation to participate in a phone survey, since they are not paid for doing so."
Blue Shield of California issued its own response, arguing that it would be better for providers and their staffs to inform patients about their contracted status and providers and their front-office staff could "be confused about whether the provider is or is not" in network.
"The Department's report exaggerates the severity of the issues and understates the extent of our corrections," said Blue Shield communications vice president Steve Shivinsky. "The vast majority of the issues raised in the Department's report have either been corrected by Blue Shield or were never caused by Blue Shield in the first place."
In any case, for 2015, Shivinksy said, the insurer is making a point of avoiding those confusions altogether; 96 percent of the the primary care physicians and specialists listed in its 2015 exclusive PPO and EPO networks have confirmed that they are accepting Covered California members, he noted.
DMHC regulators, meanwhile, said they understand the insurers' criticisms of the survey methodology and their efforts to improve, but are still considering enforcement options.
"While the Department understands these concerns, they do not change the fact that the significant inaccuracies contained in (the provider directories) resulted in a highly unacceptable consumer experience, nor do they change the fact that California consumers could not reach or did not have access to providers who were represented as being part of the (plans') network."