By Jayne O’Donnell and Annika McGinnis, USA TODAY (Nov. 10, 2013)
More than a month after HealthCare.gov and 15 state-based exchanges opened for business, consumers and even physicians are finding it’s isn’t easy or even possible sometimes to find out which doctors and hospitals are in the plans’ provider networks.
“Some states, they have it, and for some, it isn’t available. It ‘s a big unknown for the patient,” says Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, whose members manage doctors’ practices. “It’s very much up in the air.”
That means insurance shoppers often can’t choose plans that their doctors participate in — or that include doctors near them. It also means doctors may not be able to confirm they’re in a plan when consumers ask them. While consumers may now occasionally find a doctor listed on their commerical insurance plan isn’t accepting patients or is no longer on the network, at least they can reliably find provider lists and doctors at least know what plans they currently participate in.
Gilberg says he wouldn’t buy a plan “if I didn’t know if my physicians were in the network or the hospital was in the network.”
The Department of Health and Human Services (HHS) and others say there’s plenty of time for consumers to shop for plans and note many of the uninsured don’t even have doctors.
“The Health Insurance Marketplace will significantly improve access to care for people who lack affordable health coverage today,” said Joanne Peters, an HHS spokeswoman. “The good thing about the law is that now people have more options to shop for a plan that includes their doctor, whereas before they didn’t have the ease and flexibility to do that.”
The uncertainty stems from the general glitchiness that remains for some state exchanges and the federal site, HealthCare.gov, which is selling plans for 36 states that didn’t set up their own exchanges. It’s also due to the fact that insurers are still deciding what doctors they want on their networks and often haven’t even informed doctors if they are including them on their networks.
Some insurers have clauses in contracts with their existing doctors that say the doctors have to participate in any plans the insurers offer in that state. Doctors who don’t want to participate on the exchange plans might have had to opt out, which some may not have realized, says Sam Unterricht, a Brooklyn ophthalmologist who heads the Medical Society of the State of New York. And many doctors and hospitals are still negotiating with insurers over rates.
A survey released last week by the New York medical society found 40% of 405 doctors said they didn’t know how they wound up on insurers’ exchange plans. Just 6% said they chose to be on plans and 16% said they had to participate as part of a contract. The rest said they declined to participate. Three quarters of the doctors said they had never received a fee schedule from insurers for the plans.
In an attempt to cut costs, insurers are also cutting the number of hospitals and doctors they include in networks, and that’s a process that may continue through December.
“The intent is that when January rolls around, they should have all of the providers,” says Farzan Bharucha, a health care strategist at consulting firm Kurt Salmon.
It’s common that doctor and hospital networks are updated throughout the year, says Robert Zirkelbach, spokesman for America’s Health Insurance Plans, which represents insurers. And all of the networks have to meet “adequacy standards.”
In one rural area of Tennessee, there will only be two insurance carriers, and one isn’t listing any doctors yet. Another is a new co-op insurer and is still building its medical network, says broker J. Darlene Tucker, based in Scotts Hill, Tenn. Even so, she says her customers have bigger concerns now.
“At this point, clients aren’t even asking about who is in the network;” Tucker says. “They are still trying to get far enough into the HealthCare.gov website to determine what their monthly premium will be and what insurance plan they can afford.”
Some doctors say they’re still waiting to hear what rates insurers are paying — or they are appalled they are so low.
Michelle Berger, an Austin-based ophthalmologist, says she has only heard from one of the insurance companies she works with and she signed a contract to be on Blue Cross of Texas’ exchange plans. She did so before she saw the fees she would be paid, which she says are only slightly better than Medicaid.
“I’m not going to be able to take a full day of exchange patients and keep my doors open,” she says.
Peters says there will be enough doctors for the newly insured.
“We have put protections in place to ensure that consumers have choice through good access to networks of providers,” Peters said. “Consumer protections in federal and state law require health plans to include a sufficient network of providers as well as essential community providers.”
In Sugarland, Texas, internal medicine physician Elizabeth Torres says she doesn’t know what plans she’s listed on, but she does know her profit margins are so thin she won’t be able to accept many patients at rates that are lower than Medicare.
“We’re hoping to hear more information,” Torres says. “Everything’s trickling out a little at a time.”
Around some other states:
• In New York, broker James Schutzer found a 2,025-page spreadsheet of doctors when he looked up hospitals on the NY State of Health exchange recently. When he went on Empire Blue Cross’ site, he got the same spreadsheet and a “Find a Doctor Alert” that noted the individual and small group health products are “under construction.”
Unterricht says the accuracy of the provider lists will be suspect, too, because doctors may unwittingly be on an insurers list since they already accept their commercial plans. “Some may not accept new patients right away, and some may not accept new patients at all,” he says.
• In California, the provider network for individual plans became searchable Wednesday, and there’s still no access to the plans for small businesses in the Small Business Health Options Program or physicians in the networks. The state had to start from scratch building the medical network because there was no consistency in medical coding, says Sacramento broker Laurie Rood. Programmers didn’t realize each insurance company had a different physician code.
• In Maryland, the exchange does offer an option to search plans by provider and insurance company. The site compiles the list of providers so people don’t have to go to the company website to check on their own. Gene Ransom, CEO of the Maryland State Medical Society, says Maryland’s exchange plans are so similar to what’s already commercially available, the process went more smoothly than in many other states.
Like in Texas, where Berger says, “It’s a comedy of errors right now.”
Contributing: Fola Akinnibi