Covered California Patients Not Only Ones with Network Woes

Charlie Spiegel said he was "thrilled" when he learned that the Department of Managed Health Care was taking action against two major insurers that sell policies on the Covered California marketplace. The companies, DMHC says, had violated state law by listing doctors on their online directories who were not part of their network.

Spiegel, of San Francisco, is not a Covered California policy-holder, but he's having significant problems of his own with the individual policy he bought from Anthem Blue Cross earlier this year.

Here's the background: Spiegel, 56, says he enjoys good health, but had been postponing various preventive tests due to cost. Before the Affordable Care Act went into effect, he had a high deductible plan.

"I decided this would be the year to get a really good plan and get all the care done," he told me.

He decided to go with a plan that would have a higher monthly premium so that more of his health care would be covered at the time of service. Spiegel, 56, wanted to go with an Anthem plan. He called his doctor -- part of the Sutter Health system -- and his doctor confirmed he would take the insurance. Spiegel then confirmed with Anthem that the doctor was part of its network.

He bought the policy and visited the doctor for a physical and a follow-up appointment. Then he got a $600 bill in the mail.

Sutter was no longer in the Anthem network. Neither party had "bothered to tell me," Spiegel said.

That was over the summer. Spiegel had two problems. First, he didn't think he should be on the hook for the primary care visits, since he had sought what he thought was in-network care. He has filed appeals with Anthem and two more complaints with DMHC. But he also needed an in-network primary care doctor. He had developed back spasms and was in pain.

He would spend weeks trying to find a doctor accepting new patients.

UC San Francisco was in his Anthem network and has plenty of doctors. Spiegel checked Anthem's directory, but he was "looking at lists of 500 doctors." He called doctors randomly, only to find they were not accepting new patients.

Finally, he says, a UCSF receptionist pointed him to its medical center website for people looking for a doctor. Even for doctors on that list, appointments were two or three months out. At long last, someone told him of a doctor so new to UCSF that the doctor was not yet on the website. And because he was so new, he was accepting new patients. Spiegel was in.

"Now that I'm in a system and have a primary care doctor, I'm getting actual care from UC," Spiegel says, "and I'm having the usual fights with insurance companies about prior authorization, but at least now I have medical care."

Spiegel is a self-employed attorney. Since he sets his own schedule, he says, he has been able to spend time on the phone looking for a doctor or filing complaints with DMHC. What about the people "who don't have these kinds of advantages," he says. "For six months I couldn't make the system work to give me health care. I have an obligation to demonstrate the problem, because I'm one of the people who can do it."