We need open enrollment rules for Doctors and Hospitals

With the announcement that Blue Shield of California may be dropping Sutter Health physicians and hospitals from their list of network providers in Northern California, Blue Shield members are wondering if their health plans are any good. For all the good of health care reform under the Affordable Care Act consumers are learning that doctors and hospitals get to play by different rules. It’s time that health care providers should be made to honor contracts that run concurrent with the health plan calendar.

ACA consumer rules

The ACA gave us guarantee issue health insurance and open enrollment for individual and family plans. No one will be denied health insurance, but they have to enroll during the open enrollment period or special enrollment period. Once open enrollment closes you can’t switch plans or health insurance companies without good cause such as moving out of the area or getting married. In other words, you are glued to your health plan until the next annual open enrollment period even if your doctor or hospital drops out of the plan.

Open enrollment for doctors and hospitals

If the open enrollment rules are good enough consumers, they should be good enough for health care providers such as doctors, hospitals, laboratories, surgical and imaging centers, and pharmacies. All of these providers should have to sign up to provide services to the health plans members for the duration of the calendar year. They should not be able to drop out because of a contract dispute or because they suddenly don’t like the reimbursement rates of the health plan.

All providers disclosed before open enrollment

As a matter of fact, the health plans should be mandated to disclose all of their providers before open enrollment even starts. How can a consumer select a health plan if they don’t know which doctors and hospitals will be participating? This is like Detroit wanting to sell you a car or truck but you don’t know what engine you’ll get until it arrives. If a health care provider can’t sign a contract in September to provide services to health plan members in the following year, they don’t need to be a preferred provider.

Providers play by different rules

When a doctor or hospital drops out of a health plan it is the health plan member that suffers. No one seems to care about the consumer in the health care equation. It’s all about money. Unfortunately the doctor and hospital lobbies are so strong in California that they are never subject to consumer protection laws similar to what consumers must adhere to. Doctors can openly discriminate by refusing to see people who have Covered California exchange plans and there are no consequences for their actions.

Consumers are angry over the health care system

Here are a couple comments I’ve received about the betrayal of Blue Shield of California and Sutter Health as providers may be dropped from member’s health plans in 2015.

From my blog post Blue Shield to drop Sutter Health.

Crushed in Sacramento writes –

I am in total shock. Why was I NOT notified that I would not be able to keep my Sutter doctor until 1/08/2015? Why was I not informed before open season? I would have NEVER kept Blue Shield. It was sooo hard to find a good doctor. Most good doctors don’t take new patients, so when I lucked out and got my doctor who is an internist, I figured I’d have him until the day I die. I have had some very rare conditions, that he was able to diagnose within a day. I have faith and trust in him. My Doctor listens to my concerns, and we work out a plan of action that suits ME, as well as looks out for my welfare.

I thank god, I am healthy right now. I hope and pray for those who are in treatment for serious conditions, and now have this to contend with. This is so wrong on so many levels. Seems a law suit should be filed for the way Blue Shield went about this. We should all be given an open season again with an opportunity to change carriers.

Tigercat sounds off –

I feel Sutter and BSC are both using us as pawns in their negotiation game. I am an RN and work for a competitor of Sutter Health, but also understand that the executives view health care as a business first, where as I view our patient’s needs as the priority. I feel for the patients who are in the middle of a treatment regimen for cancer for example. Having to find a new Oncologist who is willing to continue the plan of care for this patient exactly as the old Sutter physician did with the same comfort is crazy. Both Sutter and BSC could care less about this part which is what angers and frustrates me to the core. I think and hope at some point they will reach an agreement. I don’t feel Sutter could tolerate such a loss, so they’re posturing…..for now. The BSC members have a little time left at Sutter, but what is happening now is so shameful on both parts. I hope the suits of both company’s read this and I hope enough people speak up. If only us members had a union to fight for them like us nurses, maybe we’d feel like we had a chance!

A small step to ensuring continuity, stability and transparency for consumers choosing health plans in California would be the following.

1. Health care providers who decide to accept insurance reimbursements from one or more of the health plans or insurance companies should have to agree to offer their services to the health plan members for the full calendar year just like consumers. Similar to individuals and families, if the provider decides to drop out of a health plan agreement, they should not be allowed back into the market or be able to sign-up with a different carrier until next open enrollment.
2. Health plans and insurance companies should be made to have all providers in their networks available for search and review by prospective members no later than the beginning of open enrollment.
3. Health care providers should be prohibited from discriminating against accepting a patient based on how they purchased their health insurance, either through Covered California or directly from the carrier.
4. All health care providers should be made to post their fee schedule for their top 100 most common procedures, tests, or examinations just like Kaiser has done.
5. Providers should provide an estimate of costs in relationship the patient’s health plan before the doctor, physician’s assistant, nurse or provider provides any treatment.

• [wpfilebase tag=fileurl id=388 linktext=’Northern California Sample Fees 2014 English’ /]
• [wpfilebase tag=fileurl id=387 linktext=’Southern California Sample Fees 2014 ‘ /]

Providers working the system

While there has been reform to health insurance plans, doctors and hospitals are operating under the old rules that never protected consumers. These providers have been jerking consumers around since the beginning of open enrollment for 2014. If the doctor isn’t refusing to accept someone’s insurance because it says Covered California on it, consumers are noticing their office visits are including more therapeutic and diagnostic charges to boost the medical group’s bottom line. In short, the patient is paying the cost because health care reform failed to regulate how the providers participate in the new marketplace.

Consumers lose while providers pump up profits

Until health insurance companies and the providers they contract with are forced to live by rules similar to what the consumers who enroll in these plans must endure, patients will always be subject to the whims of high level corporate executives who place profits before people. For all the posturing by Insurance Commissioner Dave Jones about emergency regulations to ensure adequate networks, there is no state agency that can really force these doctors and hospitals to play fair with the patients. We need legislation that will force doctors, hospitals and other providers to commit to contracts for health care services that mirrors the duration of the member’s participation in a given health plan.

California Department of Insurance

For Immediate Release: January 5, 2015

Emergency provider network regulations NEWS RELEASE

Commissioner Dave Jones issues emergency regulation at his inauguration requiring health insurers to have sufficient medical providers to provide patients timely access to care

SACRAMENTO, Calif. – At his inauguration ceremony today and immediately after he was sworn-in for a second term, California’s Insurance Commissioner Dave Jones issued an emergency regulation to establish stronger requirements for health insurers to create and maintain sufficient medical provider networks to provide timely access to medical care.

The emergency regulation issued today by Commissioner Jones today at his inauguration ceremony addresses the problems identified with access to doctors, hospitals, and other medical providers in 2014, as many health insurers reduced their medical provider networks and/or shifted to offering Exclusive Provider Organization (EPO) health insurance products with no out-of-network benefits. Consumers complained of having trouble getting appointments with doctors, traveling long distances to receive in-network medical care, or seeking care from doctors who appeared in their health insurer’s provider directory but who were not actually in the health insurer’s medical provider network.

“Californians and California businesses deserve better than what they have gotten from most health insurers and HMOs. Health insurers’ medical provider directories have been inaccurate, misleading consumers into signing up with a health insurer for access to a doctor, specialist, or hospital only to learn that these medical providers are not actually a part of the health insurer’s network. Consumers have been forced to pay huge out-of-network charges when their health insurer fails to provide adequate medical providers in their network or when care is provided by out-of-network providers without even informing or asking the consent of the patient,” said Commissioner Jones. “This emergency regulation is necessary to make sure that health insurers establish and maintain adequate medical provider networks to meet the health care needs of their policyholders, to make sure medical provider directories are accurate, and to stop the practice of surprising consumers with huge charges for out-of-network providers who provide care without the patients’ consent or foreknowledge.”

“I am grateful to the voters of California for electing me to serve a second term as Insurance Commissioner,” said Jones after being sworn-in. “As was my first term, my second term will be one of action on behalf of consumers. In keeping with my commitment to take action to protect consumers, just minutes after being sworn-in I am issuing an emergency regulation to protect consumers from health insurers with inadequate networks of medical providers.”

The Commissioner’s emergency regulation strengthens and adds new medical provider network requirements, including requiring health insurers to:

• Include an adequate number of primary care physicians accepting new patients to accommodate recent and ongoing anticipated enrollment growth;
• Include an adequate number of primary care providers and specialists with admitting and practice privileges at network hospitals;
• Consider the frequency and type of treatment needed to provide mental health and substance use disorder care when creating the provider network;
• Adhere to and monitor new appointment wait time standards;
• Report information about the networks and changes to the networks to the Department of Insurance on an ongoing basis;
• Provide accurate provider network directories to the Department and make them available both to policyholders and the public, so that those shopping for health insurance have this information as well;
• Make arrangements to provide out-of-network care at in network prices when there are insufficient in-network care providers;
• Require network facilities to inform patients that an out-of-network medical provider will participate in the non-emergency procedure or care, before the care is provided, so that the patient can decline the participation of the out-of-network provider if they so choose.

The emergency regulation will be noticed and then filed with the Office of Administrative Law (OAL) and go into effect upon OAL’s completion of its review. By law, emergency regulations go into effect more quickly than regular regulations.

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