Posted on Sat, Jul.
12, 2014 - Miami Herald
Some South Florida docs decline to accept Obamacare
By Daniel Chang
dchang@MiamiHerald.com
After being without health insurance for two
years, Miranda Childe of Hallandale Beach found a plan she could
afford with financial aid from the government using the Affordable
Care Actfs exchange.
Childe, 60, bought an HMO plan from Humana, one of the nationfs
largest health insurance companies, and received a membership card
in time for her coverage to kick in on May 1st.
But instead of being able to pick a primary care physician to
coordinate her healthcare, Childe says she repeatedly ran into
closed doors from South Florida doctors who are listed in her planfs
provider network but refused to see patients who bought their
coverage on the ACA exchange.
gI just felt that I wasnft being treated like a first-class
citizen,ff said Childe, who eventually found a doctor with the help
of a Humana counselor. gNobody, I donft care what kind of degrees
they have, should ever be treated that way.ff
Nearly one million Floridians enrolled in a private health plan
through the ACA exchange but some, like Childe, are finding that
some physicians refuse to honor their coverage — even when the
doctors are included in the planfs provider network.
Some physicians say theyfre concerned they wonft be paid for
their services by either the insurer or the patient, and that
insurers are not adequately informing doctors of their inclusion in
exchange plan networks.
gYou donft want to be in a situation where you provide service,
and turn around and therefs no contract in place to reimburse you,ff
said Jay Millson, executive vice president of the Florida Academy of
Family Physicians.
For some patients, though, the elation they felt about being
insured has been tempered with rejection at doctorsf offices.
Sal Morales, 48, of Kendall, said a physician and her staff
humiliated him when he tried to make an appointment at her Hialeah
office earlier this year.
gThey made me feel really bad,ff said Morales, who bought a
Florida Blue plan in March and qualified for subsidies to help pay
his monthly premium and out-of-pocket costs. gI felt, seriously,
like I had a horrible disease that they couldnft, or wouldnft, or
didnft want to cure, or at least see and examine.ff
Morales, who lost his employer-provided health insurance in
October when he was laid off from his job as a TV producer, said he
has been turned away by at least three primary care physicians who
are in his planfs provider network.
gI actually went to a doctor,ff he said, gand in the lobby they
had an 11-by-14-inch sign in bright yellow that said, eWe do not
accept anything from the marketplace [Obamacare]f.ff
But Morales said the worst experience was standing by at another
doctorfs office as the receptionist called Florida Blue to verify
his coverage.
gThey got into a screaming match,ff he said, gwith the
receptionist, a lab technician and even the doctor — and me at the
dividing wall, listening to all this, with about 17 patients in that
little room listening to the fact that I had what I thought was the
worst insurance on the face of the earth.
gThis person kept saying that they were not going to be taking
any Obamacare insurance because they will never get paid,ff he said.
Morales said he stood his ground, and finally got an appointment.
But he chose not to return after that experience.
He said he finally found a doctor he likes, near his home in
Kendall, and saw him for the first time July 1 — four months after
his insurance took effect.
Morales said his new doctor doesnft make him feel like ga
second-class citizen and that is important to me because regardless
of where that insurance comes from, I still pay $145 [monthly
premium].h
Health plans that consumers buy on the ACA exchange are private
insurance, even for consumers who receive federal government
subsidies.
Itfs unknown how many of the 983,775 Floridians who selected a
private plan have been turned away by doctors in their network but
Floridafs Department of Financial Services reported receiving 63
complaints from consumers who bought a plan on the ACA exchange but
could not get in to see a physician in their network.
Childe said she complained to the state and to her congresswoman,
U.S. Rep. Debbie Wasserman Schultz, who chairs the Democratic
National Committee.
Wasserman Schultz issued a statement Friday saying she has heard
from ga couple of constituentsff about this issue. gMy staff has
raised it with the Department of Health and Human Services as well
as directly with some of the insurance companies. ... I believe the
onus is on the insurers and the providers to bridge this gap and
provide reliable, consistent customer service.h
Bernd Wollschlaeger, a family physician in Aventura, said his
contracts with insurers require him to see members from all of that
insurerfs plans — unless the agreement cites an exclusion.
gOnce youfre a provider for an insurance company,ff he said, gyou
cannot discriminate.ff
Wollschlaeger said he does not ask his patients where they bought
their health insurance. But, he added, on occasion some insurers
have delayed reimbursements for patients who bought their plans on
the ACA exchange because the companies were waiting for the patient
to pay their share of the bill.
gBut itfs not significant for my cash flow,ff Wollschlaeger said
of those experiences, gnor did I see any systematic effort by
insurance companies to delay payment until the patient pays.ff
Wollschlaeger, a past president of the Dade County Medical
Association — the largest group representing physicians in the area
— said many doctors were opposed to the Affordable Care Act from the
outset.
gThere was a strong opposition, specifically by physicians in
Florida,ff he said, adding that geven though it has simmered down a
bit, whether out of resignation or exhaustion, there is an
underlying resentment.ff
Wollschlaeger said he supports the ACA, but expects it will
evolve to address issues such as physician payment rates by
insurers.
Hefs also an advocate of educating consumers about their health
plans, particularly those who may not have been insured before and
might believe that their only obligation is the monthly premium.
gThey have financial responsibility,ff Wollschlaeger said. gItfs
not a free-for-all.ff
Eduardo Martinez, an internist and vice president of the Dade
Medical Association, said doctors in private practice sometimes
donft have the resources to verify a patientfs benefits, or to be
burdened with collecting high deductibles from patients.
Martinez said his office staff has spent as much as 35 minutes on
the phone trying to verify a patientfs benefits under an ACA
exchange plan, and, he said, gyou donft always get the correct
information.ff
gTo be able to see a patient, it costs money,ff he said. gSo itfs
easier to kind of avoid those patients because you donft know if
youfre going to get paid or not, and yet you have to pay your
employees, and you have to pay your light.ff
A 20 percent drop in cash flow for one week, Martinez said, could
mean a physician in private practice goes out of business the
following week.
gNobody wants to take a chance,ff he said.
Even more vexing, Martinez said, doctors wrestle with the
question of how to plan for an ACA exchange patientfs care while
uncertain about that patientfs ability to meet a high deductible or
co-payments.
gHow do I plan for a patient who needs to have surgery thatfs a
large amount of money,ff he said. gWho do I send him to? Which of my
colleagues do I refer him to knowing that my colleague is going to
take a financial hit? The whole chain of services gets affected.ff
Martinez said physicians also are wary of the so-called g90-day
grace periodh for consumers who donft pay their premiums on time.
Under the federal rule, insurers are required to pay for any
claims filed during the first 30 days of the grace period. But
theyfre allowed to hold any claims filed during the second and third
months, and may deny those claims if the member doesnft make the
missed payment — leaving the doctor with a debt.
Not all physicians are worried about liability, though. Some may
simply be confused about their inclusion in an ACA exchange provider
network because they donft realize their contracts say they will
participate in all of the insurerfs current and future products,
said Jeff Scott, general counsel for the Florida Medical
Association, which represents more than 20,000 physicians on
legislative and policy issues.
Insurers also have been using whatfs known as a gsilent
amendment,h when company changes a physicianfs contract and
considers the doctorfs lack of response as acceptance.
gThey ... have no idea that theyfve just been signed up to
participate in a plan with a patient population who are, you know,
theyfre probably not financially well off, and they just signed up
for a plan that has a 40 percent co-payment and potentially high
deductible,ff Scott said.
Millson, of the Florida Academy, said hefs heard gvery littleh
about ACA exchange plans from the trade groupfs more than 4,000
member doctors, residents and students in the state.
The few physicians who have called are concerned that they have
not yet received payment from some ACA exchange plans — likely
because the plans are so new, he said.
gWhat wefve advised them is – as difficult as it is – you should
work with the patient to receive a co-payment or payment up front,ff
Millson said, gand let the patient go back to the insurance company
and collect it.ff
While it may not make sense to pass more financial responsibility
onto patients whose low income qualified them for government
subsidies to buy health insurance in the first place, physicians
have to protect their ability to see other patients, too, Millson
said.
Insurance companies, though, say they expect physicians to honor
their contracts.
Nancy Hanewinckel, a spokeswoman for Humana, which sells plans on
the ACA exchange in Miami-Dade and Broward counties, said the
insurer received signed consent from existing providers to
participate in the new networks.
gIn all cases, these providers voluntarily agreed to participate
and signed an amendment to their existing contract,ff Hanewinckel
said.
Florida Blue, which sells plans on the ACA exchange in every
Florida county, did not build new networks for those plans, said
Paul Kluding, a spokesman.
gBased on the contracts our providers have signed with Florida
Blue, they have agreed to treat our members regardless of how they
obtained their insurance coverage,ff Kluding said.
He added that Florida Blue has not received many complaints from
members about physicians refusing the companyfs ACA exchange plans.
Wollschlaeger, the Aventura physician, said he believes much of
this issue is due to growing pains of the health law, and that
patients, physicians and insurers will learn to work together
because the old system was inefficient.
gItfs a better deal than dealing with uninsured patients,ff
Wollschlaeger said. gIt provides patient retention, continuity of
care, the opportunity to refer patients, and ... patients come back
when you want them to come back, and not when they can afford
it.ff
Affordable Care Act numbers
Nearly one million Floridians signed up for health insurance
through the ACA exchange – the highest of all 36 states that used
the federally-run system, and No. 2 in the nation behind California,
which operates its own exchange and signed up 1.4 million
people.
Of the 983,775 people in Florida who selected a private health
plan through the exchange, about 91 percent or 893,655 received
financial aid to pay for it, according to the U.S. Department of
Health and Human Services.
Nationwide, more than 8 million Americans have selected a plan
under the ACA exchanges.
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