About a quarter of the doctors listed on the Blue Shield and Anthem Blue Cross websites as accepting Covered California insurance aren’t useable because they don’t really accept Obamacare patients or can’t be found at that location.

A couple (pdf) of five-month surveys (pdf) by the California Department of Managed Health Care (DMHC) found what patients have been complaining about for more than a year, journalists have been writing about and advocacy groups have been suing over. Insurance companies are not accurately telling customers and potential customers what doctors and hospitals are available to them.

That seems kind of fundamental to a functioning health care system. People were slow to learn that not every doctor and facility in an insurance company’s network takes Covered California patients. One of the reasons is doctors are compensated less by insurance companies for treating exchange patients. Doctors and insurers have fought from the start over who is contracturally obligated to belong, resulting in exchange networks that are smaller and, unfortunately, ill-defined.

It’s called “doc shock.” But once the shock wore off that the exchange networks are about 60% the size of the regular networks, consumers were left with inaccurate lists of those medical providers.  

The Blue Shield survey found 18% of the 1,360 doctors called weren’t at the number listed by the insurance company and 8.8% said they weren’t really part of the Covered California network.

The Anthem survey found 12.5% of the 3,272 doctors called weren’t at the number listed and 12.8% denied they were in the network. Even with follow-up phone calls, surveyors found that, overall, just 56.7% of the doctors listed by Blue Shield and 58.7% by Anthem were available to Covered California members.

The original posting of the doctor information on the Covered California website was pulled in October 2013 because it was outdated and wrong. It returned, by popular demand, with great fanfare in January but was also way too error-filled to be useful and came down within a month.

There are indefinite plans to restore the doctor/hospital lookup on the site sometime in the future. For now, the 1.2 million people who use Covered California have to go to the individual insurance company websites for the information. The information was not easy to find and, according to state, often inaccurate.

Anthem and Blue Shield dominate Covered California because some insurers chose not to participate. They have about 60% of the business.

Both companies disputed the DMHC findings. They questioned the surveys’ methodology and Blue Shield said the law doesn’t require them to account for mistakes by medical providers and their staffs. Anthem said its providers have no ethical responsibilities, nor are they paid, to answer surveys, so the results are meaningless.

Blue Shield spokesperson Steve Shivinsky told the Los Angeles Times, “The department’s report exaggerates the severity of the issues and understates the extent of our corrections.”

The department did not say if there would be any penalties assesses the insurers and has referred its findings to its Office of Enforcement.

–Ken Broder

To Learn More:

Two Covered California Health Insurance Plans Misled Consumers, Regulators Say (by Tracy Seipel, San Jose Mercury News)

State Regulators Slam Anthem, Blue Shield over Doctor Access (by Kathy Robertson, Sacramento Business Journal)

California Regulator Knocks Anthem, Blue Shield on Obamacare Networks (by Chad Terhune, Los Angeles Times)

“Doc Shock”: Why Can’t Covered California Provide Accurate Physician and Hospital Lists? (by Ken Broder, AllGov California)

Non-Routine Survey of Blue Shield of California (by California Department of Managed Health Care) (pdf)

Non-Routine Survey of Anthem Blue Cross (by California Department of Managed Health Care) (pdf)