Provider access issues plague Anthem and Blue Shield as DMHC begins investigation July 1, 2014 General Department of Managed Health Care, Covered California, Payor Contracting 0 The Department of Managed Health Care (DMHC) recently began conducting a "non-routine audit" of Anthem Blue Cross and Blue Shield of California to investigate the accuracy of the plans' provider directories and identify whether either plan violated any network adequacy laws. According to the DMHC, consumer complaints about access issues for both plans prompted the investigation. Blue Cross and Blue Shield are the only two exchange plans using narrowed provider networks for their exchange and "mirror" products. The state is looking at whether the networks are too narrow in some counties, making it difficult for enrollees to find participating providers. A California Medical Association (CMA) survey of California physicians found that there is also widespread confusion about exchange plan contracting amongst providers, with 80 percent of physicians stating they had been confused about their participation status. Health plans often use intentionally vague or confusing contracting practices, which result in consumer confusion and frustration, as physicians often do not know that they are listed as participating in certain networks. With roughly 1.4 million Californians newly enrolled in Covered California products since January, it has been difficult for both physicians and patients to identify who is in and who is out of the narrow provider networks. "We remain particularly concerned with indications of disruptions in longstanding doctor-patient relationships, as well as the prevalence of difficulties in finding in-network referrals for patients in these new individual and small group products," wrote CMA President, Richard Thorp, M.D., in a letter to Covered California Executive Director Peter Lee on the issue. "While we understand that the intentionally smaller networks of certain health plans account for some level of expected disruption, we believe other factors, which can be addressed by Covered California and regulators, are contributing to a significant proportion of reported network difficulties." CMA has urged Covered California to address this and other issues before the next open enrollment period. (Click here for more details.) As part of the audit, DMHC has hired pmpm Consulting to contact practices to ask about their participation status with the two plans. If contacted by pmpm Consulting, CMA strongly encourages the practice to respond to their questions. This is an investigation into the accuracy of the plan directories and whether the plans have violated any laws, not an investigation of physician practices. DMHC expects to complete its investigation in approximately 60 days. Findings of the survey will be released publicly prior to the next Covered California open enrollment period, which is scheduled for November 15. Having trouble finding an in-network provider or facility? Patients who are having trouble finding an in-network physician or facility are encouraged to contact the DMHC Help Center at (888) 466-2219 for assistance. We also ask that physicians notify CMA if they are experiencing difficulties finding in-network providers to whom they can refer patients so that we may raise the issue with the plan, Covered California and the appropriate regulator. Contact: CMA reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org. Comments are closed.
