Some doctors wary of taking insurance exchange patients

Now that many people finally have health insurance through the Affordable Care Act exchanges, some are running into a new problem: They can't find a doctor who will take them as patients.

Because these exchange plans often have lower reimbursement rates, some doctors are limiting how many new patients they take with these policies, physician groups and other experts say.

Shawn Smith of Seymour, Ind., spent five months trying to find a primary care doctor who would accept her as a patient. She has a subsidized silver plan purchased on HealthCare.gov.(Photo: Family photo)

'The exchanges have become very much like Medicaid,' says Andrew Kleinman, a plastic surgeon and president of the Medical Society of the State of New York. 'Physicians who are in solo practices have to be careful to not take too many patients reimbursed at lower rates or they're not going to be in business very long.'

To prevent discrimination against ACA policyholders, some insurance contracts require doctors to accept their exchange-plan patients along with those on commercial plans unless the doctors' practices are so full they simply can't treat any more people. But lower reimbursement rates make some physicians reluctant to sign on to some of these plans or accept too many of the patients once they are in the plans.

Kleinman says his members complain rates can be 50% lower than commercial plans. Cigna and Aetna, however, say they pay doctors the same whether the plan is sold on an ACA network or not. United Healthcare spokeswoman Tracey Lempner says it's up to their physicians whether they want to be in the exchange plan networks, which have 'rates that are above Medicaid.' Medicaid rates are typically below those for Medicare, which in turn are generally lower than commercial insurance plans.

Shawn Smith of Seymour, Ind., spent about five months trying to find a primary care doctor on the network who would take her with a new, subsidized silver-level ACA insurance plan.

'I definitely feel like a bad person who is leeching off the system when I call the doctors' offices,' she says.

Last week, Smith found a practice that would accept her as a patient. Caroline Carney, chief medical officer of MDwise, Smith's insurer, says some doctors 'might be participating with us, but just not able to take on new patients. It's at the doctor's discretion.'

Jon Fougner, a recent Yale Law School graduate, sued Empire Blue Cross this month because he couldn't find a primary care doctor in his new ACA exchange plan.

Fougner's experience underscores how important it is for consumers to check out doctor and hospital networks for plans before they purchase them -- and to call doctors to make sure they are accepting new patients with their policies.

Among 30 doctors he called, Fougner said, they either weren't taking new patients, weren't in the plan or didn't return calls, or the contact information proved incorrect.

'It's absolutely their right to take whatever plan they want to take,' Fougner says of doctors. But he says he found Empire's records are often 'erroneous about whether the doctor takes the plan and/or other information essential to seeing the doctor.'

Empire declined to comment as the litigation is pending.

Insurers are also moving to smaller networks of doctors and hospitals in their exchange plans. These 'narrow networks' help them reduce costs, but they can also lead to problems when consumers look for doctors who will take them.

Among complaints from doctors about how the whole system is working:

* If consumers have a federally subsidized plan, they get a 90-day grace period before plans are canceled if they don't pay their premiums. That means doctors have to pursue patients to pay for their services for most of that time as insurance companies refuse to pay the claims.

* Plans sold on the exchanges with the lowest premiums require consumers to pay the most out of pocket. Many of these customers have insurance for the first time and don't understand how much they have to pay, so doctor's offices have to spend a great deal of time explaining benefits packages, says Ripley Hollister, a primary care doctor in Colorado Springs.

Doctors' offices want it to be clear on insurance cards that a patient has an exchange plan so they know whether they want to accept the plan and whether the person is receiving subsidies - which can reduce out-of-pocket costs - or has high cost-sharing. Doctors in Texas are trying to get the state to require insurance cards to make clear whether the plans were purchased on the exchange and what metal level they are, says Austin King, president of the Texas Medical Association and a head-and-neck surgeon.

Meanwhile, the National Association of Insurance Commissioners is developing a new standard for what is an adequate number of doctors and hospitals in insurance networks. Beginning next year, the Centers for Medicare and Medicaid Services will be certifying that these networks for plans sold on HealthCare.gov are big enough. Under the ACA, consumers who have trouble finding a doctor covered by their exchange plan can file a complaint on HealthCare.gov, CMS says.

There is some good news: The number of counties with two or more insurers is up from 81% for the last open enrollment to 95% this year, which Department of Health and Human Services spokesman Kevin Griffis says 'should mean more doctors to choose from.'

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