qotd: Is your doctor in your network? Use a recorder when you ask your insurer.

Reuters
May 15, 2014
California consumers say duped by Blue Shield's limited Obamacare plans
By Terry Baynes

Consumers who purchased new health plans from Blue Shield of California
have sued the insurer, claiming they were misled into thinking the
insurance would cover their desired doctors and hospitals.

In their complaint filed in California state court on Wednesday, San
Francisco residents John Harrington and Alex Talon accused Blue Shield
of misrepresenting that their plans, sold on California's health
exchange, would cover the full provider network advertised on the
company's website.

They sued on behalf of a class of people who had purchased so-called
"preferred provider organization" plans from the insurer only to realize
that the doctor and hospital networks for their plans were limited.

Harrington bought a so-called silver plan on California's online
exchange while Talon bought a platinum plan through the insurer's
website. They said they made their choices based on Blue Shield's
alleged representations that their doctors would be covered.

After receiving medical treatment numerous times between January and
March, Harrington and Talon later discovered that their providers were
not covered, forcing them to pay the charges out-of-pocket, the
complaint said.

http://www.reuters.com/article/2014/05/15/us-usa-healthcare-blueshield-idUSBREA4E0VN20140515

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Los Angeles Times
May 15, 2014
Recording seems to refute claims made by Anthem
By David Lazarus

David Cienfuegos said his wife was told by Anthem Blue Cross that his
doctor was part of the insurer's coverage network, but then was left
with the tab for about $5,800 in medical costs after Anthem insisted
that it never said any such thing.

In this case, though, Cienfuegos, 40, has a digital recording of the
Anthem rep clearly saying his surgery would be covered.

And he's suing to hold the insurer accountable.

In its Feb. 19 letter rejecting Cienfuegos' appeal, Anthem said the
company's own records show that "no specific provider was mentioned in
the conversation nor was it noted you were misinformed about
participating status for this specific provider in question."

That's just b-i-z-a-r-r-e.

Cienfuegos' wife can be heard on the recording spelling out the
provider's name, and the Anthem rep can be heard confirming both his
in-network status and that the procedure would be covered.

http://www.latimes.com/business/la-fi-lazarus-20140516-column.html

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Comment by Don McCanne

One of the more important reasons given for using private health plans
as a basis of reform was that they were working well and people were
happy with them. The Blues - Blue Cross and Blue Shield - were held out
as prime examples of well functioning plans. Although patients did not
like being restricted to provider networks, the lists were quite
comprehensive, so it worked. But now…

Both the Blue Shield and the Blue Cross plans in California are using
more restricted networks in Covered California - the insurance exchange
under the Affordable Care Act. Even the plans with the highest coverage
- the platinum plans - are using these narrower networks.

It is a problem enough for the patients who are having difficulty
finding out which physicians and hospitals are on the plan, but these
anecdotal accounts confirm that the insurers are not a reliable source
of that information either. And when the insurers are wrong, they still
have the chutzpah to try to make their own clients absorb the losses.

Not only do individuals frequently change their coverage, the provider
lists also frequently change. Since the lists are now narrower, there is
a much greater probability that patients will lose continuity of care
because of the unstable coverage and unstable networks.

There will be many more lawsuits like these, which may then cause the
insurers to relax their restrictions. Yet far too many will still be
caught in this out-of-network trap. And the insurers will not stop
there. They will introduce yet more market innovations that will be
designed to reduce their obligation to pay for health care. After all,
they are businesses, not public service organizations.

Enough. Time for a single payer national health program.