County Pulse

County Pulse: Even doctors are confused about Covered California health plans

kcarlson@modbee.comMay 23, 2014 

A survey suggests that physicians are confused about whether they are in the provider networks of Covered California health plans.

The California Medical Association said that, in a two-day period, more than 2,300 medical practices responded to the survey on contracts with insurance products sold on the state exchange. Covered California was established to create an insurance marketplace under the federal Affordable Care Act.

The CMA, which represents the interests of 39,000 doctors statewide, concluded that patients can’t rely on the provider directories of some large insurers offering plans on the exchange. The report does not name the insurance companies. Many doctors are unsure whether their practices are part of the “in-network” team for patients who enrolled in the health plans.

Patients greatly reduce their out-of-pocket costs by getting treatment at medical offices or hospitals within their health plan’s provider network.

The CMA report said, “Many Californians are signing up for one of these new products mistakenly believing a certain physician or physicians are in the network when they are not.” Patients making appointments with those doctors are later billed for larger-than-expected balances.

Medical practices are not sure how to refer patients to doctors or hospitals that accept the insurance, said the report, which claims patient care is being adversely affected.

CMA President Dr. Richard Thorp urged Covered California to clear up the contracting and referral issues before the next enrollment period in the fall.

The CMA suggests large insurers are using their clout to pressure medical groups to participate in the Affordable Care Act plans. The association claims that physicians are being misled by deceptive language in the contracts.

Covered California has reported that almost 1.4 million consumers enrolled in exchange plans statewide between Oct. 1 and March 31. Some consumers who used the exchange had their independent-market health plans canceled by the state because they did not meet new federal standards.

Other customers previously were uninsured or dropped the coverage they had to purchase subsidized insurance costing significantly less.

The CMA survey found:

• 80 percent of physicians were confused about their participation in Covered California health plans.

• 55 percent were not sure how to refer Covered California patients to doctors or hospitals within a plan’s provider network.

• More than 75 percent of doctors thought these problems were affecting patient access to care.

The survey report, titled “Straightforward Contracting for a Stronger Health Care System,” can be viewed at www.cmanet.org under “News & Events.”

Bee staff writer Ken Carlson can be reached at kcarlson@modbee.com or (209) 578-2321.

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