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California Consumer Watchdog Files Lawsuit Against Blue Cross For Botched Up Algorithms and Misrepresentation

Posted Jul 11 2014 4:34am

We all  know the stories here in California during open enrollment and afterwards “is the doctor is or is the doctor out”.  To start out all Blue Cross and Blue Shield policies bought through the exchange paid physicians 30% less than a commercial policy which accounts for some of the confusion but not all of it.  Even doctors who agreed from the beginning to the rates foundimage themselves left of the “in network” lists.  Blue Cross and Blue Shield had to go back and re-negotiate to get more doctors to participate in network and what was added I don’t know. 

Pre-existing conditions didn’t go away, they were just transformed into “narrow networks”.  Blue Cross unlike many of the other insurers has a very large amount of individual policies. 

Pre-Existing Conditions With Health Insurance May Be Gone But Narrow Networks Are Providing The Same End Result For Many Ill Patients With Not Being Able To Get Care - Extreme Cases Of New Killer Algorithms Popping Up With Insurance Business Models…

With all the changes the data could not keep up with who was in and who was out and at some point this going to become a real big issue as is happens in other places too and everyone can’t wait for the data to be loaded up and be accurate.  People in North Carolina went without food stamps for 3 months as the systems were not available to kick out data, so we can’t wait for data all the time and compensation has be done somewhere.  We can probably blame some of this on Healthcare.Gov and those algorithms not working well with Blue Cross too and during the enrollment you know had everyone pounding for those stats.  We come back around again to the virtual values and the real world, and what counts is patients getting care in the “real world”.   Blue Cross was also the only choice for small businesses to buy via the exchange.

Small Business California Insurance Exchange Option Went From a Choice of One to a Choice of Zero as WellPoint Pulls Out–Stay Tuned As More Develops

In addition Blue Shield has their algorithmic problems with sending doctor reimbursements to the patients instead of the doctors. 

Blue Shield Billing Fiasco With Policies Bought Via Covered California - Checks Are Going To the Patients and Not the Doctors Who Some How Ended Up No Longer As Covered Providers…More Killer Algorithms Creating More Obstacles to Getting Care…

The lawsuit I’m sure is a result of the left not knowing what the right was doing around Blue Cross as it states full coverage information was not given to consumers until it was too late for them to change.  If you followed the news during open enrollment, this is a bunch of bad algorithms that didn’t come together for proper business intelligence decisions and could it be helped, probably not with all the data system chaos.  Again with not enough doctors and having to re-negotiate and shuffling the doctor data back and forth, sure we had flawed data out of all of this. 

Now another complaint that is not related to data is the failure to disclose that there were no plan offering out of network coverage either in four big counties, Los Angeles, Orange, San Francisco and San Diego.  For three months Blue Cross agreed to pay claims until March 31st where the doctor listings were messed up.  After that everyone was on their own.  What a hassle as well for consumers, more data to look up and finding out if it was accurate or not.   When plans were cancelled to offer ACA compliant plans, the trouble began.  We need simpler to navigate insurance plans both for the consumer and for Blue Cross to work with themselves. 

Insurance carrier “designed” complexities are starting to catch up as other systems that connect and work with theirs are also more complex, s time to start simplifying things.  Narrow networks are more difficult to manage it appears than pre-existing risk algorithms.  We even saw United bid and win a contract in Maryland, and due to narrow networks, no providers so they had to give up the contract of course.  BD


LOS ANGELES -- California insurance giant Anthem Blue Cross misled "millions of enrollees" about whether their doctors and hospitals were participating in its new "Obamacare" plans and failed to disclose that many policies wouldn't cover care outside its approved network, according to a class-action lawsuit filed Tuesday.

As a result, many consumers are on the hook for thousands of dollars in medical bills and have been unable to see their longtime doctors, alleges the suit filed in Superior Court in Los Angeles by Santa Monica-based Consumer Watchdog. While declining to comment on the suit, Anthem has conceded that some doctors were inaccurately listed on its plans.

Brought on behalf of Anthem enrollees who purchased individual coverage between Oct. 1, 2013 and March 31, 2014, the lawsuit reflects growing consumer push-back against so-called "narrow network" health plans, which are increasingly common under the Affordable Care Act, commonly known as Obamacare. Anthem is a major player on California's health insurance exchange, and the suit includes those who bought coverage online, as well as directly from the insurer.

The suit says that Anthem, the state's largest individual health insurer, delayed providing full information to consumers until it was too late for them to change coverage. The suit also alleges that Anthem failed to disclose it had stopped offering any plans with out-of-network coverage in four of the state's biggest counties -- Los Angeles, Orange, San Francisco and San Diego.

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