Patients, doctors seek remedy for confusion over BlueCross BlueShield of Tennessee's Network E

Patients, doctors seek remedy for confusion over BlueCross BlueShield of Tennessee's Network E

July 27th, 2014 by Kate Harrison Belz in Local Regional News

Aerial of BlueCross BlueShield of Tennessee headquarters in Chattanooga

Photo by Dan Henry/Times Free Press.

Over the last seven months, shoppers in the new health insurance marketplace have become patients, using their new plans for the first time.

Roughly 52,800 Tennesseans looking at some of cheapest plans in the country chose a brand-new BlueCross BlueShield of Tennessee network, dubbed "E."

For many, the transition from shopper to Network E patient has been satisfying. They have access to quality doctors, many for the first time, at a good price.

Others, though, are reckoning - sometimes painfully - with the fact that Network E coverage is cheaper for a reason: There is a much narrower field of doctors to choose from. And it may not include the doctor they want.

The realization has led 4,475 members to switch to the company's S and P networks, which include more doctors, Blue Cross officials said Friday.

LEARN THE NETWORKS

Your network determines which hospital system or doctor accepts your insurance. Research the insurer's website to find out which doctors are included in which network, and call your doctor directly to find out what he/she accepts.

If your preferred doctor is not in your network, consider whether you're willing to pay out-of-network costs to see that doctor, or if you should change networks.

If you're looking for a new doctor on the network, make sure he/she offers what you need. Consider the distance to the office and the average wait time for an appointment.

Source: Chattanooga-Hamilton County Medical Society, American Exchange

Meanwhile, the Tennessee Department of Commerce and Insurance has reported "100 to 200 calls" from people upset upon learning their doctor was not in the network or that they'd have a long drive to see a specialist, agency spokeswoman Megan Buell said.

Other states are dealing with the same issue. Georgia's state insurance department had received about 30 complaints regarding narrow networks, the Atlanta-Journal Constitution reported in June.

Several factors are playing into the confusion and disappointment, health experts say.

Many first-time insurance shoppers picked plans based on price, without researching the providers.

Inconsistencies on the federal marketplace website and in insurers' doctor directories meant some patients went to an "approved" place for treatment, only to find out later that the doctor was not actually in-network.

And some physicians didn't realize there was a new BlueCross network. Saying they took "all BlueCross plans," they accepted patients' Network E cards, only realizing their mistake when claims were denied.

"There was a lot of confusion with the advent of the new network," said Rae Young Bond, executive director of the Chattanooga-Hamilton County Medical Society, which represents doctors.

ABCs of E-S-P

BlueCross has the largest number of plans offered on the Tennessee marketplace.

E - The lowest-cost, most-limited network, with 1,257 providers. Erlanger Health System is the sole hospital and most of the doctors are in the Erlanger system. Network E is about 34 percent the size of Network P.

S - Includes 3,502 providers and Erlanger and Memorial Health Care System as its hospitals. Premiums cost 11 percent more than Network E.

P - The widest, most-expensive network in the Chattanooga area, with 3,705 providers. Includes Parkridge Medical Center, along with Erlanger and Memorial. Premiums are 30 percent higher than Network E.

Source: BlueCross BlueShield of Tennessee

BlueCross vice president of communications Roy Vaughn said that the company worked exhaustively to educate consumers about the different networks.

All messaging about Network E, he said, made it clear: It was for people who valued savings over broad selection.

"We want everyone to choose the plan that works best for them. That's the best business model," Vaughn said.

"To think we're going to try to confuse people or make it seem like they're buying something they're not - that's not something you do to build trust."

R. Lawrence Van Horn, executive director of health affairs at the Vanderbilt Owen Graduate School of Management, likened the furor to growing pains as people adjust to changes in health care.

"The better that the health plans are able to negotiate, the better off it is for the patients paying the premiums," said Van Horn.

But the confusion also only highlights the need for more patient education, experts say.

"The only insurance decision most of us have ever made is if we wanted to be on our workplace plan, or our spouse's workplace plan," said Bond.

"We're in a new era in which we need to be more proactive consumers."

THE TRADE-OFF

When BlueCross rolled out Network E last year, it put Chattanooga in the national spotlight for having some of the lowest prices in the country.

One analysis by Kaiser Health News showed one Network E $187-a-month policy would be $348 in Catoosa County, Ga.

"E is really good for people who are right above that poverty level. A lot of those consumers have never had health insurance or doctors," said Bobby Huffaker, CEO of American Exchange, a Chattanooga-based broker.

The exclusive Network E health system in Chattanooga is Erlanger - the region's public, academic hospital and Level 1 trauma center which has seven facilities across the region.

BlueCross dominated sales on the new insurance marketplace in Tennessee, and E was its most popular network, capturing 44 percent of marketplace buyers in the state and 53 percent in Chattanooga.

NEED TO ENROLL OR SWITCH?

Open enrollment, when people can buy individual insurance plans or switch networks, begins Nov. 15 for most people wishing to change insurance networks.

People who have "life-changing circumstances," such as losing a job, getting married or divorced or having a baby, may qualify for special enrollment now. Visit HealthCare.gov to see if you qualify.

People having problems with their network can appeal through the U.S. Department of Health and Humans to change to another network at the same "metallic level" - gold, silver or bronze. Even if HHS allows this, it is up to the insurance company whether to honor it.

"As people are becoming more price-sensitive and we're facing greater and greater out-of-pocket costs, so they are more willing to make trade-offs of how much choice they're willing to give up versus how much price they're willing to benefit from," said Van Horn.

Lekisha Jones is one of the people who was willing to make that trade-off.

The home health care worker from Brainerd bought a Network E plan in March after not having insurance for a year. She found a low-deductible plan and was granted $150 in tax credits to help her pay the premiums.

She initially wanted a particular doctor, but found one she likes just as much on E.

"I do not have to worry about my health anymore," she said. "I now know that I have a doctor I can see."

But Mark Horner, a self-employed photographer who bought an E plan for himself and his wife, said he would rather pay more to keep his current providers.

"We found out that none of the primary care doctors or specialists we use were in the network," he said.

MEDICAL MIXUPS

Even educated shoppers have been frustrated by kinks in the new insurance market.

Debbie Swann, 61, thought she did everything right.

Swann, a retired nurse anesthetist who lives in North Chattanooga, opted for Network E. An active person, she never needed more than a yearly checkup.

In May, she made an appointment with a doctor in the Network E directory. But a few days after her checkup, the doctor's office said her claim had been denied. The doctor was not in Network E, she was told.

"It's frustrating," said Swann. "You call. You do everything you're supposed to do, and then it's not right."

BlueCross officials said they were working to clear up the matter to prevent such confusion in the future. They said their own site regularly updates its doctor directories.

Buell, at the Tennessee Department of Commerce and Insurance, said the agency has investigated such problems, including the way Healthcare.gov displays doctors.

Some consumer advocates say patients shouldn't be stuck with out-of-network bills if they didn't know were out of network in the first place.

In Swann's case, the doctor absorbed the cost, asking Swann only for the original copay amount. And she has since referred Swann to another in-network doctor.

For now, Swann says she plans to stay in Network E. She likes the price. She just wants everyone to be on the same page.

"I just want them to get their facts straight," she said. "I just want to make sure I know what I'm getting."

Contact staff writer Kate Harrison at kharrison@timesfreepress.com or 423-757-6673.