Some central San Joaquin Valley residents who have enrolled in Affordable Care Act health plans are finding their doctors don't accept their new insurance cards.
Patients thought their health providers were participating in specific plans because their names appeared on lists that Covered California, the state's health benefit exchange, made available on its website.
But the lists were filled with errors, so Covered California took them off-line last month. And insurance plans have acknowledged their lists are not always up to date.
The snag with health providers mostly has affected people in the Valley who bought Anthem Blue Cross and Blue Shield preferred provider organization (PPO) plans through Covered California. PPO plans allow patients to self-refer to specialists. Patients who bought Kaiser Permanente plans are not affected because Kaiser doctors are all in-house.
Some of the biggest doctor groups in Fresno have opted not to participate in plans offered through the state exchange, saying the reimbursement is too low. Health plans counter that they've tried to keep costs down and that doctors stand to gain from an expanded patient case load.
Stuck in the middle: Consumers, many of whom have paid large premiums for health plans they thought offered a wider choice of providers. They now must choose between finding new plans or having to find new doctors who are accepting patients covered by Anthem Blue Cross or Blue Shield PPOs.
And it could be difficult finding doctors.
The 160-doctor Central California Faculty Medical Group — one of the largest private physician groups in Fresno — decided not to accept patients with PPO plans through Covered California.
"We would be paying to see patients, and we just couldn't afford to do that," said Dr. Karl Van Gundy, a pulmonologist and president of the board of directors for the group, which is affiliated with the University of California at San Francisco-Fresno Medical Education Program.
The group is a safety-net provider, and Van Gundy noted that "this is really bothering us a lot that we aren't being able to provide this service."
For some consumers, keeping their doctors is a priority. They are dropping Covered California plans and turning to the individual marketplace for coverage. Others are switching plans within Covered California.
Consumers face a March 31 deadline to change plans through the exchange.
Sharon Wilson, 60, of Visalia, thought she had found a good deal with an Anthem Blue Cross plan that cost her about $200 a month after a government subsidy. But she wound up in tears when she learned her doctors wouldn't take her new insurance card.
"If it has a little Covered California sticker on it, and you take it to the doctor's office, they almost throw it back at you," she said.
Wilson, a retired office manager, terminated the policy and bought a Blue Shield plan on the individual marketplace. She is paying $700 a month for the coverage. Her doctor said he would accept the plan — this year — but not next. "He didn't opt out of it in time this year," Wilson said.
Doctors who are not participating in plans through the exchange also are not participating in comparable plans sold in the private, individual marketplace.
But it's been a struggle getting word out to consumers that there is no difference in the providers for a private PPO plan and the equivalent plan through Covered California.
At the six-physician Spruce Multispecialty Group in Fresno, doctors do not accept any Anthem or Blue Shield PPO plan, whether or not it's Covered California, said office supervisor Barbara Cordova.
"Patients are not aware that they're paying more money and they have a limited network now, a limited formulary and less benefits," Cordova said.
The consumer's choice of hospital also can be affected by a change in health plans. Saint Agnes Medical Center in north Fresno has an exclusive contract with Blue Shield but accepts Anthem's PPO through Covered California.
Community Medical Centers has contracts with Anthem Blue Cross for both its HMO and PPO plans. It doesn't have contracts with Blue Shield for any plan offered through Covered California. The health system operates Clovis Community Medical Center, Community Regional Medical Center and Fresno Heart & Surgical Hospital.
More patients, more money
Health plans said there is another side to the doctors' story of why they're rejecting plans.
Doctors want to be paid more, but increasing the reimbursement rates would lead to higher medical costs, including higher premiums for consumers, they said.
Anthem and Covered California are working together to keep costs down, said spokesman Darrel Ng. "Tens of thousands of doctors across the state" are participating in Anthem's plans on the exchange, he said.
Health plans say participating doctors can benefit from seeing Covered California patients. Blue Shield asked providers "to sign new contracts at discounted rates in exchange for access to an expanded patient population of consumers enrolling through Covered California," said Sean Barry, a company spokesman.
But adding patients may not be an attractive incentive for many doctors in the Valley who already are busy and would have to shorten patient visit times to accommodate more.
"Can you provide the same quality of service in less time? No, you can't," said Cordova of the Spruce group.
Doctors are trying to work with patients who bought PPO plans through Covered California, Cordova said. The Spruce doctors offer a 20% billing discount to patients who bought exchange health plans that are not accepted by the group, she said.
Doctors and their office staffs are as frustrated as patients, said Sue Marino, office administrator at the 25-doctor Peachwood Medical Group in Clovis. The group doesn't have an Anthem PPO contract and is only accepting the Blue Shield PPO for existing patients, she said.
It's hard for patients to know what their plans cover and who is accepting them, Marino said. "I've spent days on the phone trying to get answers so I could help my patients," she said. "There's a lot of misinformation out there."
Enrollment in health plans through Covered California began Oct. 1 but did not get underway in earnest until December. Now, as people are making doctor appointments, complaints about provider availability are starting to be filed with the California Department of Managed Health Care, which oversees health plans in the state.
Since Jan. 1, the department has received 51 provider-related complaints out of 743 total complaints. Until recently, most of the problems have involved enrollment issues, such as people not getting insurance cards or not being able to get through to a plan or to Covered California, spokeswoman Marta Green said. But provider complaints "cropped up" in February, she said.
The department monitors health complaints to ensure that health plans are complying with state regulations, including that they have enough doctors.
California health plans must have one primary care provider per 2,000 patients and an overall doctor-to-patient ratio of no less than 1-to-1,200. More patients can be seen if physician assistant and nurse practitioners are working under a doctor's supervision.
Health plans try to comply with the state rules.
Blue Shield has added doctors to its network in certain counties to meet the standards, and it's confident it can "meet the needs of 2014 customers," Barry said.
But that can be little comfort to health consumers whose new insurance cards have been turned away at doctors' offices.
Jeri Kuddes, a real estate agent in Prather, bought a Blue Shield plan through Covered California in October. The platinum plan was one of the most expensive — the monthly premium is $1,600 — and Kuddes said she checked to see if her doctors would accept it. They said they would.
But in February, Kuddes said, her doctors refused to sign new contracts with Blue Shield, and she was stuck with an expensive insurance plan: "Not only had I paid a high premium in January, February and March, but I had to pay for my office visits."
Kuddes dropped her Covered California plan this month and bought a private plan. The new Anthem Blue Cross plan costs her $2,000 a month.
She has been assured her doctors will accept the plan — but she hasn't had to use it yet. "I have some appointments in April, so we'll see."
Who to call
For complaints about health plans: California Department of Managed Health Care at www.HealthHelp.ca.gov or (888) 466-2219
The reporter can be reached at (559) 441-6310, email@example.com or @beehealthwriter on Twitter.