LA Times.com reports, “Top Insurers Overstated doctor networks, California regulators charge,” by Chad Terhune, 11/18/2014, http://www.latimes.com/business/la-fi-obamacare-network-probe-20141119-story.html#page=1.
The issue, as stated in the article were the low number of provider participants offered by Obamacare plans by Anthem and Blue Shield which “account for 60 percent of enrollment in Covered California,” (LATIMES, Chad Terhune, 11/18/14).
Also of note, individuals were unaware of the inadequacy, the “…narrower networks and more restrictive policies were a jolt to many people and often came to light only when they were getting treated," (LATIMES, Chad Terhune, 11/18/14).
This is part of why Obamacare was less of REFORM and more of an aggregation of worst practices. This problem was easily identifiable prior to the PPACA.
In 2009 I wrote: The very poor have the Medicaid option. The very rich don't worry about health insurance. The middle class, that has shelled out billions and trillions over its lifetimes to purchase insurance coverage that ultimately is inadequate to assist in paying for needed medical care when they get sick is the root of the "crisis", http://conoutofconsumer.blogspot.com/2009/09/what-messand-still-cost-of-getting.html.
But in a law that was ill-conceived, sloppy and sacrificed essential consumer issues, we had the lukewarm lip-service of the Act’s section 1311, Affordable Choices Of Health Benefit Plans and under section C requires the Secretary of HHS to make sure that qualified health plans “ensure a sufficient choice of providers.”
HHS essentially left the establishment of such standards to the states in 2012 when “Network Adequacy Standards,” “The Establishment of Exchanges and Qualified Health Plans final rule permits discretion for Exchanges in setting network adequacy standards for QHP issuers…a network that is sufficient in number and types of providers so that services will be provided without unreasonable delay,” Department of Health and Human Services, https://www.cms.gov/CCIIO/Resources/Files/Downloads/hie3r-ria-032012.pdf.
Fast forward to today’s 11/2014 article in the LA TIMES and we find that for consumers stuck with narrower networks California “…hasn't determined what penalties, if any, will be imposed on the insurance companies,” (LATIMES, Chad Terhune, 11/18/14). So far in six months a follow-up survey by the state is planned, (LATIMES, Chad Terhune, 11/18/14).
The article ends with a quote by “Brett Johnson, associate director for policy at the California Medical Assn….’we definitely hope the audit will have a deterrent effect on the health plans’."
The HOPE strategy. But in the real world where doctors hope, states plan another audit in six months, and insurance companies deny any problems, what are consumers to do?
In California, consumers have lawsuits against the insurers based on misrepresentation, usually an element of trying to prove fraud. Just like the useless HIPAA laws, proving the intent to deceive is often a barrier making such lawsuits difficult.
For the rest of us, filing appeals with insurance companies and outside reviewers about denial of claims, et cetera, can be of value. Additionally, where possible, consumers should call providers who are on participating provider lists and find out if they actually do participate in your plan.
Under PPACA adequate networks are required that avoid unreasonable delay in being able to obtain care. But the responsibility is pushed to states to define and enforce such standards, and likely California and its residents are only among the most publicized concerning the problem of thin networks, that existed before Obamacare and exist after Obamacare. Again, another indication that the PPACA is not revolutionary, but more just a codification of business as usual.
