Wellness

Are Doctors Refusing To See Obamacare Patients, Or Are Insurance Companies Just Playing Hard To Get?

The insurance companies I deal with have made it harder for me to see Obamacare patients than any other patient I have.

We’ve been hearing stories about problems with the ACA (Obamacare) insurance exchanges lately. Now patients are buying the insurance, only to find that doctors refuse to see them. Why should these patients have so much trouble finding a doctor? Is it because Obamacare is terrible insurance? Is it because they’re terrible patients?

Well, as a practicing physician who does see Obamacare patients, neither of those problems have been my experience. In fact, my experience has been far stranger. Basically, for reasons they haven’t revealed, the insurance companies I deal with have made it harder for me to see Obamacare patients than any other patient I have. Here’s the story:

I’ve always been willing to take Obamacare patients, and two of the insurance companies I accept sell policies on the ACA exchange in my area: Anthem Blue Cross and Blue Shield of California. I’ve accepted both plans since 2003, so I assumed there’d be no problems with seeing patients who bought their policies on the exchanges. When Obamacare patients called, my receptionist always assured them I could take their insurance.

But then my office started getting denials from Blue Cross—and only for the patients who bought their insurance on the ACA exchanges, not for other Blue Cross patients. At first we called the Blue Cross claims dispute department and they said they had no idea why the coverage was denied, so we should just re-bill them.

We’ve seen a lot of “mistaken denials” from insurance companies, so re-billing is standard. But the claims were denied again. After a few rounds of this we finally decided to contact their provider relations department. Here’s where the story gets strange.

Provider relations informed us that I was not credentialed to see these patients because I had not filled out the special form required for their ACA network. Now, no one told me about this form, and no one at Blue Cross ever asked me about whether I was willing to see these patients. Remember, even their claims dispute department didn’t know about this “special” requirement, which was why they didn’t think anything was wrong.

So, I filled out the form and, by late summer 2014, I was finally in their ACA network and Blue Cross was finally willing to pay me for patients I’d been willing to see all that year.

That was one company, how about the other? At first Blue Shield gave me no trouble. They even sent me a letter in late 2012 confirming that I was in their ACA network. I’d been seeing Blue Shield patients since 2003, so it never occurred to me that would be an issue. Then last March, with no explanation, Blue Shield started refusing to pay claims.

Again, we called. Blue Shield said I was no longer in their network of ACA providers. They said they felt they already had enough doctors in that network, so they didn’t need me anymore.

Wait… what!?!

Blue Shield removed me as a provider for patients who were already in my practice, without telling me and without telling my patients in advance... because they had too many doctors?

Still a bit confused (nothing like this had ever happened to us before) we asked Blue Shield to please put me back in their ACA network so I could resume treating my ACA patients. And Blue Shield said: “Why?”

I’m not kidding. We asked Blue Shield of California to restore me to their network of ACA providers and they asked, “Why?” as in “Why would I want to see these patients?”

Well, Blue Shield did finally send me the forms to get back into their network, though they refuse to pay for the ACA patients I saw before I found out they’d taken me out of the network. And after I filled out the proper paperwork, they told me I was allowed back into that network.

Then they promptly changed their minds again. Why this time?

It turns out the hospital I’m affiliated with (Alameda Hospital) has been having a contract dispute with Blue Shield this year. Since Alameda Hospital won’t take Blue Shield patients during this dispute, I’m told that I can’t see these patients either.

“Um, does that mean I don’t get to see any Blue Shield patients?”

“No, just the ACA patients.”

Now, wait a minute! First, I’m not employed by Alameda Hospital. Being able to admit patients there has nothing to do with their contract disputes. Second, Alameda Hospital also hasn’t signed a contract with Blue Cross, Cigna or Aetna this year, and none of these insurance companies have a problem with my seeing their patients. Finally, Blue Shield doesn’t have a problem with my seeing any other Blue Shield patients because of this dispute, only those who bought their insurance on the exchange.

Of course I’m sure there are doctors who really don’t want to see Obamacare patients for reasons of reimbursement (these policies do pay me about $10-$15 less for an office visit than most other private insurance policies), or politics, or any other reason. But I was willing to see these patients, and the insurance companies appear to be going out of their way to make it painful for me to see them.

Why?

I don’t think it has to do with money. Blue Shield of California didn’t claim any losses on their ACA members in 2014, and I doubt the $40 they pay me for an office visit is breaking them.

What I do know is that nearly every health insurance company has opposed the ACA from the beginning—historically, insurance companies haven’t liked the government playing in their sandbox. Maybe by discouraging doctors from seeing these patients, they can make a case that the ACA just isn’t working. Whatever the reason, the next time you read a story about how difficult it is for Obamacare patients to find a doctor, remember, it isn’t just doctors refusing to see them.