Narrow networks: Is your doctor really taking that insurance plan you bought?

Filed Under: Costs, Patients, Providers

 

CHCDocsNetworks

SUMMARY: The networks of doctors on New York State health insurance plans are changing by the second. Doctors are learning now,  just days before the deadline to sign up for Affordable Care Act insurance, that they are not in the networks they thought they were in. Patients who thought they’d bought a plan including their docs may get a big surprise when they try to deploy their insurance in January. Information is hard to come by in general, I happen to know, since I’m buying insurance on the New York exchange. And then, when  a person from a billing office nearby called to tell me what she knows, things got really interesting.

 

 


When the phone rang, the voice on the other end of the phone was apprehensive. She works in a doctor’s billing office in Long Island, a New York suburb, and she wanted me to know that the beginning of January will be chaotic for health-care consumers, and not necessarily for the reasons you think. What’s happening on the ground is not always pretty.

She wanted to make two points: people buying insurance plans think they’re getting one network but they are actually getting something entirely different. And people who are on high-deductible plans are in for a rude surprise.

First, the networks. They are becoming what’s called “narrow networks.”

Her doctor’s office wanted to make sure they participated in the network. Let’s just say it’s a big network that shall remain unnamed (but whose initials are Magnacare). Early in the fall, she said, this office was told it was part of the networks of several insurers; now, they have learned that the networks used by the insurance companies in question are not full “Magnacare” but “Magnacare Extra,” which implies that it’s “Magnacare plus something else,” but actually — in her description — is “Magnacare with a bunch of providers removed.”

And their practice was removed.

Early in the signup season, she said, they got in touch with eight exchange insurers to make sure they’d be included. They received assurances, which they passed on to patients. Now they are told they are a member practice with just one exchange insurer.

So if you asked your doc earlier in the fall “Do you take Oscar?” or “Do you take Health Republic insurance?” you might have gotten a “yes.” But at least at this doctor’s office, the “yes” turned into a “no.”

What happened?

She said she was told that the insurers creating their networks “invited physicians, depending on demographic and hospital affiliations — if you don’t have privileges” at certain hospitals, you won’t be part of the network. So they wanted to be in, but were excluded.

Another caller told us a different reason for why the networks are changing: Doctors and other providers are themselves opting out.

He said  many doctors received a revised fee schedule in the mail from insurance companies, fairly late in the game (after the Oct. 1 enrollment period had started). He said he knows docs who looked at the lower fees and decided not to take part because the lower fee schedule was not appetizing. Therefore, some networks include doctors who are willing to work for a lower fee schedule–or doctors who were able to negotiate higher fees.

Other Providers Also Out of Networks

Other providers are also learning they’re not on exchange plans, despite what they’ve thought and what they’ve been telling patients.

I called OneMedical yesterday, because I’m shopping for a GP and looking to match provider and plan. (Yesterday is Dec. 19, and the deadline for signing up is Dec. 23. I already wrote about this here and here.)

OneMedical is not accepting any New York State of Health plans, I learned. “We just got that information from our credentialing team,” said Molly in the Midtown location at 49 Fifth Avenue.

“We were trying to get credentialed,” but it didn’t happen, she said, offering little explanation. She did offer a refund of the annual membership if I wanted it. (OneMedical is a membership group; you pay a membership fee for the year, which entitles you to their suite of services.)

My current GP’s group is also not accepting any New York State of Health plans.

Trying to find out what providers are included in the Empire plans on the exchanges still gets no results — the site directs you to a 2,000-plus-page spreadsheet that crashes both Chrome and Firefox browsers, as it did last time I tried earlier this week.

The Facebook page of the New York State of Health is full of comments about this too (click on the screenshot for details).

My billing department friend went on to say that they expect chaos Jan. 1, when patients appear in doctors’ offices, expecting that they have bought a plan that includes their doctors, only to find out that’s not true.

The High-Deductible Shock

Further, many patients who will be newly in high-deductible plans will have a big shock coming, she noted. This includes patients not on the New York State of Health, but on existing employer-sponsored or other plans.

Say someone came in for care, expecting a $30 copay or a $50 copay, but now they’re converted to a high-deductible plan, with a $2,000 or a $10,000 deductible.

“If they come in for a problem visit, she hasn’t met her deductible, let’s say she has Empire — we have to charge her the normal and customary of what her health plan allows,” she said. “It could be $220.

“A lot of these patients are going to be knocked on their butts and saying ‘I can’t pay that.’ ”

My friend from the Long Island office added, “Nobody is addressing the providers’ perspective here.”

Asked if she blamed this on the Affordable Care Act, she said not in the least. “This has been coming for a long time,” she said.

As I write this, the New York State of Health web site is announcing that it is down for regularly scheduled maintenance–at midday, three days before the deadline to sign up.

Update: New York exchange networks still changing

UPDATE: The network situation on the New York exchanges is changing by the second, from the looks of our reporting. Who’s in your network and who’s out? You may find out only when you show up at the door — and the situation could change after the turn of the year, or before: providers are still negotiating with payers.

Looking for hospital coverage information, I found this web clip about NYU Langone taking only a limited number of plans on the exchange. The same source offers this about Empire networks. Also, there’s this clip this about Memorial Sloan-Kettering. MSK is still in conversations with a number of other providers, reportedly.

A Metafilter link to these issues is here.

An AP story about New York hospitals’ choices is here. Roni Rabin’s piece about lower rates on the exchanges via Kaiser Health News is here. A blog discussion is here.