Even doctors in dark on health plans

Insurers still working on provider lists add to the confusion

Jayne O’Donnell and Annika McGinnis

More than a month after HealthCare. gov and 15 state- based exchanges opened for business, consumers and even physicians are finding it isn’t easy or even possible sometimes to find out which doctors and hospitals are in the plans’ provider networks.

“Some states, they have it and for some it isn’t available. It’s a big unknown for the patient,” says Anders Gilberg, head of government affairs for the Medical Group Management Association, whose members manage doctors’ practices.

That means insurance shoppers often can’t choose plans that their doctors participate in — or that include doctors near them. It also means doctors may not be able to confirm they’re in a plan when con- sumers ask them. While consumers may now occasionally find a doctor listed on their commercial insurance plan isn’t accepting patients or is no longer on the network, at least they can reliably find provider lists, and doctors at least know what plans they currently participate in.

Gilberg says he wouldn’t buy a plan “if I didn’t know if my physicians were in the network or the hospital was in the network.”

But the Department of Health and Human Services and others say there’s plenty of time for consumers to shop for plans, and they note many of the uninsured don’t even have doctors.

“The Health Insurance Marketplace will significantly improve access to care for people who lack affordable health coverage today,” said Joanne Peters, HHS spokeswoman. “Now people have more options to shop for a plan that includes their doctor, whereas before they didn’t have the ease and flexibility to do that.”

The uncertainty stems from the general glitchiness that remains for some state exchanges and the federal site, HealthCare. gov, which is selling plans for 36 states that didn’t set up their own exchanges. But it’s also due to the fact that insurers are still deciding what doctors they want on their networks and often haven’t informed doctors if they are including them on their networks.

Some insurers have clauses in contracts with their existing doctors that say the doctors have to participate in any plans the insurers offer in that

“I’m not going to be able to take a full day of exchange patients and keep my doors open.”

Michelle Berger, an Austin- based ophthalmologist

state. Doctors who don’t want to participate on the exchange plans might have had to opt out, which some may not have realized, says Sam Unterricht, a Brooklyn ophthalmologist who heads the Medical Society of the State of New York.

A survey released this month by the New York medical society found 40% of 405 doctors said they didn’t know how they wound up on insurers’ exchange plans; 6% said they chose to be on plans; and 16% said they had to participate as part of a contract. The rest said they declined to participate. Three- quarters of the doctors said they had never received a fee schedule from insurers for the plans.

It’s common that doctor and hospital networks are updated throughout the year, says Robert Zirkelbach, spokesman for America’s Health Insurance Plans, which represents insurers. And all of the networks have to meet “adequacy standards.”

Some doctors say they’re still waiting to hear what rates insurers are paying — or they are appalled by how low they are.

Michelle Berger, an Austin- based ophthalmologist, says she signed a contract to be on Blue Cross of Texas’ exchange plans before she saw the fees she would be paid, which she says are only slightly better than Medicaid. “I’m not going to be able to take a full day of exchange patients and keep my doors open,” she says.

Peters says there will be enough doctors for the newly insured.