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Health Insurance Exchange Problems Hit Patients, Practices Hard


You might be surprised to find out that you are out of network for many of the new health plans.

Wow, what a week!  What a year, I should say.  The state of California has seen many, many changes since January 1. How these changes are affecting physicians and practices is mind-boggling. 

Here are a few of the biggest changes practices are experiencing:

1. A new California law allows patients to walk into a physical therapy office without a prior prescription and receive treatment for a specific number of visits or days.  The problem is that some insurance companies still require a prescription from a licensed physician. 

Unfortunately, insurance companies often don't share this information at the verification level with the physical therapist, and the claim is denied or delayed in payment.  This has been a treat to figure out, but most of the patients have primary-care physicians that the physical therapist can fax the evaluation to, and this seems to satisfy the insurance companies need for a prescription.

2. The next change relates to the California workers compensation fee schedule.  It transitioned from very specific 30-minute timed codes to the Medicare Fee Schedule.  The problem is that very few of the workers compensation plans actually implemented this change and they are pulling the, “We didn't know” card.  Senate leaders in Sacramento have filed complaints against many of these plans. Liberty Mutual, your time to pay up has come! 

I strongly advise practices to review their workers compensation claims with their healthcare and billing staff to make sure they are using the updated fee schedule, that the workers compensation plans are paying per the fee schedule, and that someone is following up with these types of claims.

3. Our latest fiasco has been my favorite so far:  Covered California. It really should be called Uncovered California.  This blog article is certainly not long enough to list all of the fiascos that we uncovered this week, but let me name a few. 

Blue Shield created a “narrowed network" and many physicians that participate with Blue Shield are not in network on the new exchange plans. That means that if a patient purchases a Blue Shield exchange plan and calls for an appointment and a practice's front-office staff mistakenly believes it is in network, the patient may have to pay out-of-network rates around a 50 percent coinsurance for receiving services at your practice.  

I have identified a common group number of X001004 and alpha prefixes of XEA, XEC, XED, XEK followed by 900.  These two are tip-offs that the patient is on exchange, off exchange, or underwritten.  All of these scenarios claims are processing out of network.

Some of the health cards have the “Covered California” logo on them, some don't.  All of the plans indicate that they are some sort of PPO, so practices usually don't think twice about not being in network. 

Patients are angry and up in arms about all of this.  While trying to figure this all out, I came across the Blue Shield Facebook page. If you want a laugh, take a look.  The company's canned responses are similar to the recorded messages and disclaimers you get when you call. 

Blue Cross of California also has several new plans in which many providers are considered out of network.  Practices in the state of California may want to spend a few hours to identify patients with the alpha prefix JQD, JQM, JQN and VXB with corresponding group numbers of 0RX, 0RY (zero not “O”). 

It is imperative that practices discuss these out-of-network issues with their staff so that they are aware when patients call and start yelling about getting their bills.

What health insurance exchange problems have you experienced in your state?

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