BCBS Sued for Misrepresentations of Networks

Santa Monica, CA - Blue Cross vastly misrepresented the size of its physician and hospital networks and other key health plan contract terms in order to increase sales during the Affordable Care Act’s ‘open enrollment period’ that ended on March 31, according to a new California class action lawsuit filed by Blue Cross customers and consumer advocates.

“Blue Cross used false information about its provider networks, deductibles, and other key terms of its coverage to trick consumers into enrolling in the company’s new health plans,” said Laura Antonini, staff attorney for Consumer Watchdog. “Blue Cross also collected premium payments from many consumers for months without providing consumers with proof of coverage, preventing them from accessing medical treatments and services. Additionally, Blue Cross is operating a customer service telephone system that virtually guarantees consumers will remain in the dark about their plans by subjecting them to incredibly long hold times and dropped calls.”
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Additionally, the Consumer Watchdog and Shernoff Bidart Echeverria Bentley LLP lawsuit announced today alleges that Blue Cross violated California laws by:

• Subjecting consumers to inadequate networks of physicians and hospitals, causing delays and interruptions in accessing needed health care;
• Misrepresenting and concealing that its new PPO plans imposed much higher deductibles for out-of-network providers than advertised for the plans. As a result, consumers must pay far more out-of-pocket before Blue Cross pays for medical care;
• Delaying consumers’ enrollment in new health plans for months, effectively blocking access to physician and hospital services, even though Blue Cross collected consumers’ premiums; and
• Subjecting consumers to exceedingly long wait times, regularly lasting several hours, on customer service telephone lines when consumers called to address these problems and misrepresentations.

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Jon Fougner says his simple search for a doctor through the insurance company website turned into a ‘Dickensian nightmare.’ Some doctors did not accept new patients, others never returned his calls, and some had wrong contact information listed on the Empire BlueCross BlueShield website, he claims. He accuses Empire of breach of contract, fraud and false advertising.
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He says he used the “find a doctor” function on Empire's website to track down a doctor near him who was accepting new patients, and 30 names came up.

He called the first doctor, who turned out to be working at an HIV clinic and not accepting new patients, the Manhattan Supreme Court suit says.

The second listing had the wrong phone number for the doctor, and when he got the right number, the doctor never returned his calls.

Doctor three turned out not to even work in Manhattan. Others had their phones disconnected, or said they didn't accept the insurance, says the suit - which includes a pie chart of the panoply of problems he had with all 30 listings.

He says he called Empire for help and to complain numerous times, and when he was finally able to get a human being on the phone, the person said he would send him a list of available doctors. He was eventually emailed a list of the same doctors and with the same bad contact info, the suit says.

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A Texas couple who switched health care plans thought they were getting a good deal until they tried to use it.

But then, they started to look for a primary care doctor.
"So we started to look around and try to find a physician and that's when I start to get really nervous," William said.

The Lyles estimate they called about 20 doctors listed as Molina Healthcare providers, but none would accept their insurance.

Doctors say it's not just a paperwork problem. They claim some insurance networks are shrinking.
"We've seen networks that were extremely narrow, meaning even in Dallas you know with all the healthcare systems here," Dallas County Medical Society head and Aids Arms CEO John Carlo said. "We have patients that the nearest network provider is in Waco. That is simply not acceptable."

"The insurance companies have nothing to lose by not keeping their provider manual is up to date," Read said. "The Texas Department of Insurance does not ride herd on the insurance companies. They do not enforce the law to require them to have adequate network of physicians."

The Lyles, who live in Plano, now have an appointment with a primary care physician in Dallas, but they're worried. Especially as they try to find a specialist for William.

"I'm still pretty nervous about them," William said. "I don't know if they're going to be able to really take care of her health care needs."

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Charlene Lake thought she got a decent deal through the Affordable Care Act marketplace: a Humana HMO that included a family doctor a few miles from her home.

Five months later, Lake wonders if she can even use the insurance she bought.

Her plan's dominant health care provider, JSA Medical Group, recently announced that it would take no new patients covered by Humana's exchange HMOs at least until fall. That leaves Lake no choice but to use the community health centers left in her plan's network, rather than the traditional physician's practice on which she planned.

But aside from first-year fumbles, the case also shows the downside of limiting consumer choice of physicians through what is known as narrow networks.

Or, in Lake's case, a network so narrow it barely exists.

"You can't make people sign up for a health care plan and then not have a doctor," said Lake, a St. Petersburg antiques dealer who is in her 50s.

Narrow networks of hospitals and physicians help insurers maintain profitability while holding down premiums and complying with ACA rules. Insurers have more leverage on medical prices when dealing with a smaller group of doctors and hospitals.

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“I am a self employed psychotherapist in New York City. I had health insurance through December 31st when my policy was canceled.

I bought an ACA policy in mid-November and had to fight to obtain my insurance identification number the entire first week of January. I did not receive my id number until January 9th.

Now, I still can’t use the insurance — even though I have an id number — because none of the doctors that I know who are actually taking the insurance have been placed on Blue Cross’s website as being in the ACA plan network.
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I am still left with having to pay out of pocket to see my pain management doctor onJanuary 15, 2014.

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A Smith County district court has granted an injunction to East Texas Medical Center Tyler, immediately designating the hospital as a preferred provider in the Blue Cross & Blue Shield of Texas (BCBS) preferred provider organization (PPO).

Additional Links
ETMC files $1 million suit against three major health insurance carriers
“We have been fighting hard to allow Blue Cross & Blue Shield PPO members to have real choice in their healthcare options,” said Elmer G. Ellis, president/CEO of the ETMC Regional Healthcare System. “This decision is a victory for those who value competition, choice, and access to the widest range of local hospital services.”

Earlier this year, ETMC Tyler filed suit against Blue Cross & Blue Shield, citing that the hospital’s exclusion from the organization’s preferred provider networks has created serious and negative impacts on a large group of consumers. In fact, according to Blue Cross & Blue Shield, 30,000 East Texans in Smith County alone are covered under its PPO network.

The suit noted that ETMC is the only level one trauma center in the area, as well has providing the only renal transplant and deep brain stimulation services. Patients needing their services were told that ETMC was out of network for their BCBS of Texas PPO.

“We were forced to take the drastic action of filing this lawsuit to ensure access to the many services offered at ETMC Tyler for this large group of consumers,” Ellis said.

Because of this ruling, physicians can refer Blue Cross & Blue Shield PPO patients to ETMC Tyler, where they will receive all in-network benefits, including lower deductibles and copays.

A similar lawsuit was filed in November 2014 by Texas Spine & Joint Hospital in Tyler against Blue Cross Blue Shield. The hospital said it was seeking damages for what it called years of disputed payments for patient care provided to BCBS members. The hospital also argued that BCBS is in violation of the Texas Free Enterprise and Antitrust Act by having only one contracted or “in-network” hospital facility in the Tyler area.

ETMC administrators expect Blue Cross & Blue Shield to appeal the court's decision.

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BCBS of Texas said that the decision to end their PPO plans was not reached lightly, but in 2014, their individual market claims exceeded premiums by $400 million. Switching to an HMO model is expected to help the carrier keep their individual products sustainable under the new rules that prohibit medical underwriting.

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An Overland Park woman is suing Blue Cross and Blue Shield of Kansas City, claiming the company intentionally misled consumers about which physicians they could visit through the company's Affordable Care Act insurance plans.

Debra Simon, in a petition filed in Jackson County District Court, alleges the company marketed its plans as including a specific network of providers. Simon said she checked with Blue Cross to ensure those doctors would be covered prior to purchasing the policy, "and the Blue Cross website indeed displayed the names of the doctors."

But after she and her family sought care with those providers, she said she was billed for seeing out-of-network doctors.

"Blue Cross's practices were at best deceptive and unfair, and at worst constituted a deliberate 'bait and switch' aimed at attracting greater amounts of customers and insurance revenues," the petition said.

The lawsuit was filed as a class action including any BCBSKC policyholders who purchased a plan with fewer in-network providers than was advertised to them. It includes violations of the Missouri Merchandising Practice Act as well as unjust enrichment.

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JumpinJack said:

Lawsuit: Blue Cross and Blue Shield lied about physician networks on ACA exchange
According to Vern and Sangha, a person who makes such claims about the ACA is lying.

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Heather Tralla or Northridge enrolled in a Blue Shield-subsidized Covered California plan — the “Enhanced PPO Covered California” plan — last fall. She has multiple sclerosis and, in mid-January, a doctor referred her for two MRIs. Tralla said she logged into her account with Blue Shield to look up facilities that would accept her insurance.

She then spent more than two weeks trying to find a provider. While her online account showed many facilities, when she called the offices all said they did not accept Covered California insurance. They said they would accept the “Enhanced PPO” plan from Blue Shield, but not the “Covered California” version. She said supervisors she spoke to at Blue Shield initially told her that the two plans have the same network — then others told her they have different networks.

Ultimately, Tralla called one of the MRI providers so many times that the office finally called her in early February to say that the provider had signed a contract that day to accept the Covered California plan. She had her two MRIs late last week.

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I contacted Steve Shivinsky, a spokesman for Blue Shield, who told me the networks for their “Enhanced PPO” plans are the same. “It doesn’t matter if you purchase (the plan) on or off the exchange,” he said via email.

But that has clearly not been Tralla’s experience. “I got my MRI taken care of,” she said. “But what’s going to happen the next time?”

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RabidAlpaca said:

Is it really necessary to create 7 new threads in the same section within an hour? Do you just start a new thread for every news article you read then wander off to the next one?

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JumpinJack said:

I'm done, now. These started with a frustrated post I did recently about not being able to find a doctor who would accept my Blue Cross HMO ACA plan purchased through the exchange, using the network provider list. I was pretty upset about it. There are two posters who follow me and others around, and bombard posts that contain anything negative about the ACA with posts that the OP is lying. Both Vern and Sangha have repeatedly posted in response to my posts by outrightly calling me a "liar" or saying "you are lying."

Normally, that rolls right off. But I thought in this instance, since their insulting posts were stalk-like and so numerous, that I would, finally, post some proof that my situation was not unusual. For those to be lies, there would have to be some really complicated collusion going on by people in various states to get together and "lie."

There were too many to list in one post. I posted one, then I saw another, then I saw another case. They'll get spread out later and not appear together. Sorry.

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JumpinJack said:

Because Vern and Sangha posters, among other posters, have outright called me a "liar" for various problems I've had with the ACA....

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JumpinJack said:

Income is too low to qualify for a subsidy, and I don't qualify for Medicaid.

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JumpinJack said:

You don't know much about the ACA, do you? You have to have an income higher than $12k to get a subsidy. But you can have assets.

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JumpinJack said:

Yes, it is. That's why I won't have to pay a penalty. I COULD withdraw from my retirement account, which would count as taxable income. But that's money I need for my old age.

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JumpinJack said:

I never said I made lower than $12k, so you are misremembering and altering past statements to fit your perception.

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RabidAlpaca said:

I think part of the problem is that with so much hyperbole about the ACA floating around, largely from the "Obama is a muslim tyrant trying to ruin America" crowd, legitimate criticism is often grouped into the same category and attacked. Even with the ACA our health care system is severely and systemtically flawed and is in need of massive reform.

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gdgyva said:

depending on the network, state, and coverage getting reimbursement for your patients care can be a red tape nightmare

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JumpinJack said:

Because Vern and Sangha posters, among other posters, have outright called me a "liar" for various problems I've had with the ACA since I began using it in 2014, I post some evidence for some of the problems that have caused me much grief, and hours of wasted time, not to mention no preventive exam as yet this year.

Blue Cross Sued for ‘Bait & Switch’ Misrepresentations of Doctor and Hospital Networks, and Delaying Enrollment in Affordable Care Act Plans

In 2014:


Blue Cross Sued for ?Bait & Switch? Misrepresentations of Doctor and Hospital Networks, and Delaying Enrollment in Affordable Care Act Plans | Consumer Watchdog

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JumpinJack said:

Plano Couple Has Trouble Finding Doctors Who Accept Their Insurance
(this is about Molino Ins.; Plano is a burb of Dallas. Dallas has many large medical complexes, and untold thousands of doctors, not to mention huge hospitals throughout the area. A medical mecca.)



The husband calls the policy a "bait and switch."

Everyone blames everyone else, of course. And Kaiser (an ins. co.) says, "9 out of 10 insured Americans are satisfied with their choices of doctors and the value of their health plans." Of course Kaiser is lumping "insured Americans" together, and not singling out where the problem is: individual ACA plans.

One provider told me point blank that they take my plan....if it's a group plan. But they won't take it as an individual plan.



Plano Couple Has Trouble Finding Doctors Who Accept Their Insurance | NBC 5 Dallas-Fort Worth

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"The Texas Department of Insurance does not ride herd on the insurance companies. They do not enforce the law to require them to have adequate network of physicians."

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JumpinJack said:

Because Vern and Sangha posters, among other posters, have outright called me a "liar" for various problems I've had with the ACA since I began using it in 2014, I post some evidence for some of the problems that have caused me much grief, and hours of wasted time, not to mention no preventive exam as yet this year.

Blue Cross Sued for ‘Bait & Switch’ Misrepresentations of Doctor and Hospital Networks, and Delaying Enrollment in Affordable Care Act Plans

In 2014:


Blue Cross Sued for ?Bait & Switch? Misrepresentations of Doctor and Hospital Networks, and Delaying Enrollment in Affordable Care Act Plans | Consumer Watchdog

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JumpinJack said:

I'm done, now. These started with a frustrated post I did recently about not being able to find a doctor who would accept my Blue Cross HMO ACA plan purchased through the exchange, using the network provider list. I was pretty upset about it. There are two posters who follow me and others around, and bombard posts that contain anything negative about the ACA with posts that the OP is lying. Both Vern and Sangha have repeatedly posted in response to my posts by outrightly calling me a "liar" or saying "you are lying."

Normally, that rolls right off. But I thought in this instance, since their insulting posts were stalk-like and so numerous, that I would, finally, post some proof that my situation was not unusual. For those to be lies, there would have to be some really complicated collusion going on by people in various states to get together and "lie."

There were too many to list in one post. I posted one, then I saw another, then I saw another case. They'll get spread out later and not appear together. Sorry.

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