Now I Have Insurance. But I Can’t Use It. What Am I Supposed to Do?

A THCB Reader in New York City writes in to say —

“I am a self employed psychotherapist in New York City. I had health insurance through December 31st when my policy was canceled.

I bought an ACA policy in mid-November and had to fight to obtain my insurance identification number the entire first week of January. I did not receive my id number until January 9th.

Now, I still can’t use the insurance — even though I have an id number — because none of the doctors that I know who are actually taking the insurance have been placed on Blue Cross’s website as being in the ACA plan network.

Thus, I can’t change my primary care and I can’t get a referral for my pain management specialist (I have nerve damage in my spine due to a surgical complication). So, I have an insurance policy but I can’t see my doctors who have decided to take the ACA insurance. I essentially have purchased insurance that I cannot use at the present time and I don’t know when I will be able to use it unless I go to the few doctors they have put into their system.

I have been talking to the New York State Department of Health and so far, their aid if you will call it that, has been useless. I am still left with having to pay out of pocket to see my pain management doctor onJanuary 15, 2014.

This is something no one is talking about — that those of us who were insured, who have tried to keep some doctors, who have inquired and found doctors who say they are taking the insurance — that utilizing these new policies due to referral requirements is next to impossible.
Many of the doctors listed on their networks do not exist. I have called many of them. My guess is this will be talked about in two to three months when more people find they can’t use their policies. BUT NO ONE IS TALKING ABOUT IT NOW and it’s driving me crazy because it is happening now.

The government representatives I have contacted and asked for help are of no help. They have no plan in place to deal with these problems and they don’t appear to think the problem of not being able to see your doctor is important enough to deal with. Since it’s not happening to them, well, you know….”
If you have questions about the Affordable Care Act or your buying insurance on the federal state exchanges, drop us a a note. We’ll publish the good submissions.

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  1. I would be willing to bet that most of the respondents here still voted for a Democrat or a Republican when the 2016 elections rolled around. What was it Einstein said – about the definition of insanity?

    To address the actual topic, with some perspective as a few years have gone by, this was my experience with Obamacare. I registered for a plan during the initial November signup period, with BCBS. The Marketplace accepted the registration, and BCBS never got it. Fixing the mistake couldn’t be as simple as faxing the relevant documents over, oh no. The case had to be reviewed (supposedly within thirty days), at which point the case worker was supposed to figure out what had happened and send the information so I could actually be insured. Several months went by, and the case was “escalated” several times, to no effect. Every supervisor I talked to claimed it was impossible to figure out who was managing my case, and refused to do anything about it, the only solution being to wait for the negligent or overworked caseworker to notice it at some point. I maintain that it could have been as easy as sending a fax, but whatever.

    A little over four months later, they finally got the paperwork, and I had insurance. BCBS claimed that I had retroactive coverage for those four months and charged me for it, though. No one I talked to held out much hope for a solution – despite the fact that I had no way of using the insurance during those months – aside from voiding the policy and starting over, sending it back through the very same system. I paid.

    For the first year, the subsidies were reasonable, given the obscene cost of healthcare in the US, and the monthly payments acceptable. Finding a practitioner who accepted “Blue Select” was nigh-on impossible. There were a couple of general practitioners in the area (each with a three month wait time for an appointment), but aside from them, I had my choice of two clinics, each about an hour’s drive. I tried them both and was a little disturbed; both of them felt a lot like the free/”poor clinic” of their respective areas. Dingy buildings, young doctors hesitant to prescribe or do much of anything (though there was a great hospital right across the road, where Blue Select was pretty much laughed off). The goal seemed to be to throw the cheapest options at the problem first, then move forward, in sequence, and reluctantly. The cost – not my health – was always the primary consideration.

    Because it takes so much effort to research the labyrinth of policy options (not to mention proving my identity to the Marketplace, which somehow, uselessly, involved Experian, and was its own battle), I kept it for several years anyway. I did find a very good dentist who accepted it, but dropped it as time went on. She was new at the outset, and explained that the company just wasn’t willing to pay enough for “Select” members.

    I think the subsidies remained relatively constant, or dropped off a little, but the premiums skyrocketed. Not sure why, but within two years, the monthly price of my (relatively useless) plan had doubled. I was forced to drop it, and haven’t been insured since.

    As an aside, here’s an experience that illustrates the problem of healthcare in the US, in a nutshell. I went to an in-network hospital to get two routine x-rays. I’d forgotten my insurance card at home, so I got them done anyway and paid the cash price: $75 each. Hoping for a reimbursement, I brought the insurance card in the next day, and was told they’d send the claim off.

    A month later, I got a bill for about $3500. Apparently, the claim they sent the company was for $1700 and change, per x-ray, which BCBS refused to pay. They resubmitted the claim, at which point BCBS paid for one (but charged it to my deductible, so actually paid nothing), and denied coverage for the other. I had the receipts, showing that I’d paid the cash price of $150 for everything, but it still took me two months before someone at the hospital was finally able to cancel the debt. By that point, I had been contacted by a collection agency.

    If you aren’t a fan of Obamacare – which was and continues to be a disaster – be aware that the failure was largely a result of political infighting between Democrats and Republicans. The bill as a whole passed, but enough portions were defeated that it was crippled, making it a sort of sad, expensive joke. To a citizen, that’s a shame; to a Republican, it’s a windfall – ammunition to be used in the next election. Democrats, of course, blame the Republicans. Anyone can see the devastating effect this is having on the country (see also, government shutdown). No one on Earth should have to put up with this, but I guess you did vote for it.

    To the two people who are going to read this, I suppose this is my message. As long as you maintain US citizenship, get ready for more of this kind of thing in every aspect of your life, becoming exponentially worse as people elect one major party over the other, over and over again, and wonder why nothing changes. The national debt and the state of paranoia and “security” (aka the police state) and the national debt will keep growing, while very little of substance is done at the national level. The ridiculous squandering of everything America could be will continue until it reaches a state of crisis, or – judging by voter support through Trump/Hillary – until the country collapses, because apparently no one in the US can count past two.

    Sorry for going on about politics in a healthcare thread, but this is the reason why healthcare is still an issue. Plenty of other countries have it sorted.

  2. I am in California and I am having the exact problem you are having with my Doctors office. I got into a argument with his office personal and have been denied an appt with my Dr that I see monthly under the guise that it’s an insurance problem. My insurrance allows me to go out of network and I even found a wonderful ins rep that called my Dr’s office and informed them that I would just have to continue as a cash patient and they have still refused to allow me to obtain an appointment with my Doctor. Check with patiences rights groups , and good luck . I am enlisting the help of an attorney to resolve my issue.

  3. I think mass elder poverty is part of the reason my friend died. He didn’t want to call an ambulance because of the cost. I am terrified of living well into my 90s. What for? To have a horrible quality of life? To be impoverished? To be alone at the mercy of healthcare providers?

    I don’t think so. I’ve got another plan here!

  4. Thank you, John. They’re making it as difficult as possible and our representatives are not helping at all. You go to the government and you just get more red tape.

    A friend of mine in his early 60s who went YEARS without healthcare in the middle of New York City, who worked as a psychotherapist with the poor (who were fully covered by Medicaid) died last Wednesday.

    He never got an Obamacare policy. He was so sick, in so much pain and struggling with so many bills that he couldn’t even imagine getting a policy. Knowing this man, he would not have known how to navigate this system. He could barely manage email let alone the internet. Can you imagine finding providers when you’re not internet-knowledgable?

    He’d spent 10 years in his 40s working on his PhD. He told me it was like being in the military. By the time he got his PhD, he was in his 50s. He was worked like a dog by the nonprofits here who provide services to Medicaid patients and don’t even care enough about their clinicians to provide them with ANY benefits.

    I felt like a cab driver when I had that job. I didn’t get paid if the patients didn’t show and they had better benefits than I did.

    My friend didn’t survive this situation. Obamacare was too little too late. Or let’s just say it was a whole bunch of nothin’ too late!

    So you can imagine how I’m feeling this week.

    It only gets worse.

    If this man had gotten the care he deserved, he’d be alive today. Considering the kindness he showed the population he was working with, it’s downright shameful.

  5. Thanks John. I appreciate your appreciation!

    The Medicaid estate recovery nightmares are rarely for hospital bills. Most hospitals forgive their enormous bills when the patient has no ability to pay. This is done quietly, one patient at a time, so the word does not get out.

    Instead the asset recoveries are for nursing home costs. What is going on here is that people are living longer, but the amount of money they earn and save is not keeping up with life expectancy. As you suggest, the scope of this problem is quite enormous. It will take another New Deal of some kind to prevent mass elder poverty.

    One way to characterize

  6. Spot on, Bob Hertz. Even with Medicare there is a difference between the supplemental private policies and Medicare Advantage. Last year was the first time I left original Medicare for a MA plan, but my wife remained with Medicare. We learned about four years ago that people with more expenses are better off (financially) with Medicare, but MA is a better deal for healthy people. For starters, where we live the premium is zero, I presume because they are working to increase enrollment. It’s more about money than medicine, it seems.

    You’ve been at this for some time. Have you any sense of where the politics is headed? Clearly the notion of “repeal and replace” is nothing more than a slogan. There are too many positive features that will never go away. And as the president said, they can’t repeal it mostly because it was a Republican plan to begin with.

    The assessments at your site are excellent, by the way. I just love this:

    Medicare has been an enormous success, but it is not self-financing. A senior who gets a hip replacement does not go out and earn more money and increase tax collections. Saving lives is expensive twice — first when we do it, and then with higher Social Security and Medicare costs in the decade of extra life. I have often thought that doctors should be taxed for saving elder lives, not paid to do so.

    Are you aware whether enough Congressional policy makers are paying attention to make correctives? Better yet, do you have anyone’s ear (even if you are not at liberty to say who)? I sure hope so. Every time I listen to stump speeches and talk radio it makes me sick. Surely they know better, but they keep on with the same tired soundbites.

    Aloson’s case is a nightmare, but the financial impact of medical bills is totally catastrophic for many whose entire net worth gets wiped out. When they can no longer work they are at the mercy of whatever Medicaid services are available where they live — and lately I’m seeing reports of states going after estates post-mortem with those five- or ten-year lookbacks, taking what little might have been deeded over too late to the next generation — who will face even worse prospects if changes are not made.

  7. Thanks for sharing, Alison. I feel bad for what you have gone through.

    Seems to me that narrow networks are a secret strategy of the insurers to cope with guaranteed issue.
    Before 2010, insurers in the individual market could turn away sick people, and they did so in large numbers. And/or they drove off sick people tjhrough relentless premium increases.

    All they can do now is to make their plans very unattractive to sick people, and to drive off sick persons with awful service.

    Expanding Medicare down to age 55 would have been far better than the ACA in this regard.

  8. Gotcha, John. You have clarified yourself completely here.

    I am happy that the working poor have coverage and I supported the ACA for that reason. My complaint is that there is little discussion amongst Democrats of the real problems with the ACA and little focus on improving things. It’s about fighting the Republicans to keep the ACA. So, in the midst of this, those of us forced onto it are part of an experiment. To say that it was poorly implemented is an understatement.

    Here and there you see an article with a horror story but this issue of the insurance companies not contracting with enough providers — or any at all in the beginning — is very problematic and it was very distressing to me to be in the middle of recovery from a serious nerve injury and to face not only NO care even though I was paying for insurance, but a drastic cut in my income as well. And then when I was as Little Red Riding Hood might say “lost and alone,” my Liberal comrades were downright mean.

    I am still without a neurologist! Having a serious NERVE injury, I have no neurologist. Working on it. It takes time to replace eight doctors. And we all know the insurance companies know that. Think of how much money they’ve saved just with me by taking away my doctors and making those visits impossible.

    I was a Democrat but I experienced a side of my party that was incredibly nasty, indifferent, and downright mean. And I was just a person having problems. I wasn’t even making a political statement in the beginning. I have been a supporter of the ACA in theory. I was very frightened and I couldn’t rely on my local Democratic representatives to help me, those who advocated and fought for this legislation, those who weren’t even interested in the people who were getting hurt by it and weren’t lifting a finger to help. It was quite disillusioning.

    They should be ashamed. I left the party as a result. I am now independent, and the party has lost what most of the time could be counted on as a vote.

    A single sole proprietor in her 50s gets fucked by Obamacare. Who cares?

    There’s nothing anyone can say to make me feel better. If you could wave a magic wand and make my nerve better and let me run again (I can’t), that would make me feel better. That’s the only thing. I just want my health back. And I’m having to fight every step of the way, every single little thing. You have no idea what this is like (or perhaps you do if you’ve struggled with illness). I am alone with this. It is the most difficult thing I have ever faced.

    So now, when I do get to a doctor, particularly at the hospital centers the Obamacare folks want everyone to go, you know these centers for care where they’ll take of everything, well, the hospitals incorrectly charge ALL THE TIME and of course, they’re always over-charging. The insurance companies don’t even process claims properly. For example, my copay for routine labs is $0. I was billed $35. This happens all the time. Now, that happened occasionally with my prior insurance, but it’s happening much with every single visit to a hospital clinic for my primary care. I am not getting the one free preventive visit, and my low copays are not happening. It’s a big fat lie.

    I think the hospitals are making these small errors in their favor and hoping that people will just pay as it’s not worth their time to fight. Of course, for me, it’s the principle; I’m not going to pay what I don’t owe, and so it’s a hell of a lot of correspondence and in terms of my time, I’m essentially losing more money.

    So, I pay more for less, I’m nickle and dimed to death, I can only generic medications (nothing else!), and I’m terrified of becoming seriously ill because my options here in NYC will be very limited and there will be a fight for everything. When I’m sick and alone, that’s what I’ll be facing. Already I can’t get my medications at various pharmacies due to the government “protecting” me from myself.

    I know these things happened before. But they didn’t happen to THIS extent and that’s what no one’s getting. Talk to anyone on one of these plans and they’ll tell the same thing. It’s a fucking mess and we’re the guinea pigs and it’s our lives at stake, our retirements, our peace of mind. It is absolutely terrifying.

    If I could leave this country and go back to Canada and work there, I’d do it in a heartbeat. But I can’t as I”m a licensed professional and stuck in New York. Another example of government “helping” with licensing. Now, I can’t work anywhere but New York. I feel so incredibly hampered by government interference in my life that I fear I’m going to become, oh no, a Republican!

    And get this — I could go to any number of hospitals in this city with my prior plan. My roommate had leukemia and went to Sloan Kettering and lived. They send me requests for donations but now, with my ACA policy, they won’t let me in their door if I had cancer. I’m shaking my head as I write this. The audacity.

    Thank you for your thoughtfulness. There’s nothing anyone can do. I’m basically fucked for a while. I hope it’s okay to swear on this thing. Life is miserable enough as it is recovering from a serious nerve injury (unless you’ve had one, you just have no idea, it’s not even possible). Let me put it this way — I would have preferred my leg broken in a couple of places and staples and metal put in to the nerve injury (where there’s nothing they can do apparently).

    I just didn’t need another form of hell in the form of Obamacare. I already have one that is bad enough.

    Oh my. I’ve become a bitter person. I never thought it would come to this.

  9. Alison, I doubt anything I write will make you feel better. But for the record I neither said nor inferred that ACA was aimed at keeping health care providers in line. In fact, I said almost the opposite,..

    It’s too bad no public option… was allowed among the exchange choices. It would be a Medicare/Medicaid hybrid, and the existence of such an option would be a powerful incentive to keep both insurers and the health care providers in line.

    Believe me when I say I’m totally sympathetic with the problems and challenges you have faced and still do. It’s no comfort to say this, but lots of people face deep income cuts, up to and including the complete loss of their job. I have reached retirement, but in the course of my career I once took an income cut so deep our children qualified for reduced price lunches at school. Fortunately I recovered and eventually paid the max into Social Security over twenty years. But careers that never have any setbacks are few and far between.

    As for skin in the game, I did, in fact, work in a health care system after taking an early retirement from food service. I saw up close and personal the stark difference between the private sector and a so-called “not-for-profit” health health care system which was awash in money — marble floors, live plants, flat-screen TVs, concierge food service, industrial-sized laundry and landscaping departments and employee benefits I never imagined. I never knew what PTO was and sure didn’t have both 401(k) AND a defined-benefit pension plan. I realized THAT revenue stream comes from one main source — medical bills. I’m sure there are endowments, charitable contributions and tax considerations, but the serious money comes from seriously big bills. It’s no mystery that America has the world’s most costly medical care in the world.

    As for ACA, unless SCOTUS and/or the GOP succeed in destroying it, there are now some ten to fifteen million people who have health insurance that were previously not insured at all (leaving that many more and then some STILL uninsured). I worked all my life with the working poor — people for whom “medical care” means enduring sickness, pain and injury as long as possible then going to the ED when it gets unendurable. As far as I’m concerned there is much to be done before America’s health care system becomes the world-class system it should be.

    Let me repeat what I said at first — I did not say ACA was intended to keep health care providers in line. And I have plenty of complaints about how it was crafted and continues to be having problems. But the mess we call health care in America was a mess before ACA and will continue to be a mess even if it is destroyed. For example, even as we speak the “Doc Fix” (which Congress has neglected to correct since 1997) is an ongoing embarrassment which last time I checked meant 29% reduction in your income — and that preceded ACA by a decade.

    I really hope your health care issues are resolving and your practice flourishes enough to generate enough for your retirement. At times like this I wish I were wealthy enough to just write a check and make it all better. But all I can do is wish you the best.

  10. This all occurred with the ACA so I’m not sure this is simply an “insurance” issue versus “governence.” It’s the law that caused insurance costs to go up for MOST (even my corporate patients have high deductibles now and higher costs) and this is because ACA demands that MORE be covered.

    The result is MORE is covered by LESS doctors.

    Look, I don’t know what the answer is, I really don’t, but what’s disturbing to me is that I see almost no newspaper coverage of the fact that none of us can find quality doctors and someone with a brain tumor can’t get care.

    Good job, good job, Obama. What a big fat liar.

    Health care providers who take the ACA plans — and I’m one of them — take at least a 20% cut if not more to provide services to members. I do it myself as I’m one of the victims of the ACA but my guess is that other providers might not be so inclined to take such a cut.

    John Ballard, keeping us “health care providers” in line? Would you take a 20% pay cut to fund the ACA? I have. Do you have any skin in the game? I’m really just curious, not trying to be rude here but I’d like to know your thoughts on taking a 20% pay cut to fund ACA. Would you do it? Do you believe in it that much? That’s the cut I took, and my health insurance costs rose while I was in the midst of a terrifying health crisis (and I got little sympathy from ACA supporters).

    Would you personally go for that at over 50 years of age and when you have to save for retirement? What do you think this has done to my potential to save for retirement?

    This is a matter of some people paying for ACA and others not at all. It has to be paid for somehow, and perhaps the public option would have been the fairest of them all.

    I hear from other providers who take Medicare that Medicare is often six months behind in paying them. Providers are people who get paychecks that they then take home to pay their rent, their grocery bills, etc., etc. “Providers” is another word for a group of people who are being expected to foot this bill.

  11. I am going through this right now. I was diagnosed with a brain tumor at the end of the year before my insurance was canceled. (Turned 26) I got a new plan thanks to the ACA but now, I have no doctor I can use. I do agree that this is an insurance issue and not governance issue…but I just want to express my deepest sympathy to you. I know exactly what you are going through.

  12. This must be the shortest post at THCB ever to receive so many words in the comments thread. If nothing else it underscores the fact that insurance and health care are not the same. Health care providers and insurance companies are both involved with risk management, but while doctors manage health risks, insurance companies manage cost risks. It’s a toxic mixture to be sure.

    It’s too bad no public option (eliminating the insurance industry) was allowed among the exchange choices. It would be a Medicare/Medicaid hybrid, and the existence of such an option would be a powerful incentive to keep both insurers and the health care providers in line.

  13. Hey there, Elaine. He wasn’t nice, was he? I didn’t really understand these responses. My original post was posted without me knowing it actually be posted (I had sent in an email not knowing what these folks were going to do with it). I don’t mind that they posted it but they didn’t use my name (I am AKA THCB NYC if you didn’t figure that out from these posts.Then these guys accused me of making all of this up and hiding behind the name the blog assigned me. Like did it matter what my name was anyway? Anyone can make up a name.

    The unfortunate thing that I try to tell folks who are supportive of Obamacare — and I have actually been one of them — is that they should WANT to know what the problems are instead of attacking a consumer who is saying “Hey! There’s trouble here!” I really didn’t know what to do and in fact did not replace the bulk of my doctors and went without needed healthcare. That was not accidental; that was the way the insurance companies funded the first year — by making it difficult for consumers to use their insurance and hiding behind the “this is all new and we couldn’t possibly be prepared” line.

    BCBS in New York got into trouble because they had almost NO network and I went after them via the health department as did others (I’m assuming). See this story:


    It wasn’t just that people couldn’t get ID cards. We couldn’t even get through to Empire BCBS for 2 to 3 weeks! I went through their lists of doctors trying to find specialists and, for example, they had six doctors listed in New York City for pain management. That’s it. Guess what? I called all six of those doctors and there was only ONE that actually existed and took the plan. So, that’s one out of six. Not very good odds, was it?

    When you look at a provider listing for almost any health insurer, you need to know that it’s a LIE. They don’t update the information, they rely on providers to do it and they make it difficult for providers to do so. Every insurer has a different way of doing it and it’s cumbersome. So when a doctor leaves a practice, he doesn’t tell the insurance company, and the insurance company doesn’t mind because his name on their network list makes it look longer.

    This issue of false networks is not being addressed anywhere that I’ve seen. They all do this and it should be illegal. They should be forced to provide accurate information. All it takes is calling the providers’ office. it takes assigning a few employees to manage the listing. That’s it. It’s not rocket science. A clerical worker could be trained to do it.

    2015 update: Empire BCBS’ network is larger now for Obamacare enrollees. They were forced into it. You know what the benefit to me was as a provider? For the first time, BCBS allowed mental health counselors into their network. We’d been fighting them for years and voila! Along comes Obamacare, they need providers for mental health, and so now I’m on their panel. I know it’s a deal with the devil but I don’t mind. The Obamacare policies pay 20% less than the corporate policies. So, if Obamacare takes over, I’ll be looking at a 20% pay cut over the next few years.

    I wonder who would be happy about that? The other dirty little secret of Obamacare: providers are partly funding it being forced to accept reduced payments. This is why doctors don’t want to take Obamacare enrollees. I do because I’m sympathetic but it’s very easy to weed out someone who has an Obamacare policy. Sad but true.

  14. Bobby Gladd You are a nasty, uncaring inhuman being. People like you make me want to puke.

  15. Vince, you have NO out of NETWORK benefits. Now, the health insurance companies have to have, in theory, a sufficient number of providers on their panels. This is in New York overseen by the Department of Health. So, in Texas, you have to find the government body that will assist you. You need a neurosurgeon most likely and they have to have some neurosurgeons on their panel; if not, they have to pay somebody to do it — or they have to have an orthopedic surgeon who does back surgery. But you do not have any of network benefits with an HMO.

    This is the dirty little secret of Obamacare that its supporters — and I included myself as one of them at one point and in theory I would be in support of everyone having insurance — don’t want anyone to know OR they don’t even know this at all and are extremely ignorant. We have all had to deal with panels and not having enough providers. What Obamacare supporters don’t seem to get is that it is a sham because it’s not a matter of having to call around a lot and maybe finally getting a doctor, it’s that the contracts were not even in place and the networks barely created for these particular policies. When I bought BCBS in 2014, they had not even contracted with many doctors AT ALL.

    So you have insurance with no doctors available. Wonderful. Great. Thank you, Mr. Obama.

    You have to fight even harder for what you need and you have to get the state to help you. Good luck with that. But the insurance company is OBLIGATED to have a provider who can perform the surgery you need and if they don’t have one, they are capable of making special deals with out of network providers. But I wouldn’t try an out of network provider first. You can’t. You have to try their network.

    When I had spinal fusion, a plastic surgeon had to sew me up after the second surgery to repair the “equipment failure.” He was not in network but because of the circumstances, my health insurance did pay (this was an Oxford plan and Oxford is generally a better company than Blue Cross, generally, depends on where you are).

    So, you have to make a lot of phone calls to prove that the network does not have the doctor you need. They will also try to find you a doctor that will perform the surgery and you will have to see the doctors that they recommend.

    If I had crappy insurance, I wouldn’t be inclined to have a serious back surgery by just any doctor.

    Aren’t you able to change plans at this time? I thought we are still in a period where you can. Have you considered looking for a better plan? I’m not familiar with Texas but in general, in New York, the better insurers are BCBS, Oxford, United Health, Aetna, and Cigna. Most doctors take these insurers however they will not necessarily take the Obamacare plans. BCBS has gotten its act together to some extent.

    Obamacare shoved individuals onto the marketplace, the people who could least afford it, rather than corporations and small businesses. They were exempted the first year. So, we got experimented on. It was even worse in 2014.

    Look at some of the responses to me on this blog. People accused me of lying, of not being a real person, and they were very blase — “we all have problems with insurance networks.” They had and have no clue what it is like to deal with these Obamacare policies.

    You have to fight and fight a lot because no one in politics will help you. The Democrats are too invested to admit there’s anything wrong and the Republicans are so against Obamacare that we are lost. And of course, if you had to get one of those plans, you’re inherently irresponsible.

    It’s not pretty is it? I finally found a decent primary care after four tries and he and I both talked about how scared we are due to the dismantling of our healthcare system.

    And I am a provider as well.

  16. My problem is that I have a Blue Cross Blue Shield of Texas HMO self-paid plan. Most Drs. within the network do not accept patients within the HMO plan. I have a general Dr. within the network, but none of the OB/GYN’s accept the HMO plan. Need a well woman physical or pregnancy check up? Sure, it’s covered under my plan, but there are no doctors who accept my plan within my network. It’s B.S.

  17. Hi, unfortunately I had to sign up for state assisted health insurance as I was loosing mine due to work. I went to the Health.Gov website, very nice people there 24/7. For the most part very knowledgeable. I had about 10 plans to choose between 3 companies. Long story short, I picked a plan that I thought suitable. The fine tiny print I didnt research, my bad. The fine print is an EPO, “Exclusive Provider Organization” plan., they say they pay 94%. There list of Dr’s like everyone keeps stating is there are none to be found on their preferred list.
    I went to an orthopedic surgeon on their list, He does not do the kind of surgery I immediately need. He explained to me that I HAVE NO out of pocket benefits. The Healthcare.Gov and Amerihealth networks could have cared less that I need this surgery immediately. My only option I see is it is all out of my pocket, its a 34,000 surgery. Can anyone help who may be reading. Honest to god I need this neck cervical spine fusion immediately.

    Thank you, God Bless.

    Vincent H

  18. Sadly I have found the same thing this week. My job doesn’t offer insurance, so I was thrilled that I could afford the “same plan” I had access to through a previous employer. Now, 2 weeks in, I can’t see any of my doctors and I haven’t been able to get my prescriptions. Big problem and it wasn’t at all explained when I purchased it. 🙁

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  20. Kelly, I’d be happy to help you with this but this forum can be hostile at times and I’d rather just help you out directly. Please feel free to email me at abowleslmhc@gmail.com and we can talk.

    It may be true that Blue Cross is forcing their providers on the plan. At least, new providers HAVE to take us (I know because I’m one of those new providers). Note that Blue Cross is paying 20% less to any provider who takes a patient who is in the exchange network.

    I was someone who initially bought Blue Cross only to find out that I lost all of my doctors and there were almost no doctors in the network — they hadn’t bothered to contract with anyone for this insurance. It should have been highly illegal — what they did — but no one seems to care as we are a minority of people suffering. Look at some of the hostile responses to my initial plight. To be honest, I found it quite hurtful. Here I was in physical distress, illness, and my confusion and anger was met with hostility and distrust.

    My guess is when everyone else starts going through this, they’ll do something about it. In the meantime, we are on our own.

    Feel free to email me and we’ll exchange numbers and we can talk on the phone.

  21. I too feel so frustrated with my Empire Blue Cross insurance ( pathway). I have the Silver Guided Access which I pay almost $500.00 a month for and i find that almost no doctors take this insurance in fact I feel as if I have the “plaque “when i asking if a particular doctors takes it! Even when you going to their website that refers you to Doctors that are supposed to be in network most don’t take it! I’m really confused as to why I pay so much and get so little? Why do doctors not take this insurance can someone explain it to me? I originally had Blue Cross through the government and I paid a little bit more but i found virtually every doctor excepted my insurance. What’s the difference? When i talked to someone from Blue Cross they told me by Jan 1st 2015 most doctors that except the regular Blue cross will be forced to except the pathway. Does anyone know anything about this? thanks

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  24. You’re probably right. That was the writer of the Salon clip, which I would guess is more generalist than a Sara Kliff-type specialist. Part of that bad debt relief may be anticipating improved health care averting expensive (and avoidable) complications resulting from not addressing treatable conditions. What a concept, no?
    In any case, hospital debts are not on my list of worries. I’m still riding the “hospitals are money-laundering centers” hobby horse.
    In other news, somewhat related, I just learned lately that policy-makers have quietly changed an important feature of several public assistance programs — including Medicaid, TANF, SNAP and perhaps others. The adjustment has been to tweak or even eliminate the “assets” test for such programs and measure only income to qualify. The people who study the effectiveness of assistance programs finally documented what common sense already knows — that when people are forced to “spend down” all their assets in order to qualify for assistance, the result is a forced dependency on those programs. But when they are allowed to have reliable transportation (an asset) or a place to live (an asset), a savings account (an asset) or a retirement plan (an asset) but they are in a place in life where they have lost or reduced INCOME, then it’s a nutty idea to make them piss away all their assets before giving them food stamps, temporary assistance, WIC benefits and Medicaid.

    This change actually started without fanfare during the Bush years, and has been continued and expanded with Obama. It’s a secret, apparently, that is also — wait for it — bipartisan. Even Republicans in the know are on board with the idea. It must be a big secret, so don’t tell anyone.

    I would offer links, but it’s probably best to let people think it’s just wishful thinking or some socialist dream. Drill around and see what you discover. If Thomas Pikkety did nothing else he underscored the difference between income and assets. I’ve waited years to see that happen.

  25. Thanks for the additional info on the woodwork effect.

    The states which are getting hit by the woodwork effect are those which, by and large, made Medicaid hard to get……….either by setting the eligibility at a repulsively low level, i.e. $8000 income a year, or by setting up bureaucratic hurdles.

    Now these states, most of which are in the South, and most of which have a pretty racist legislature, are being hit with some extra costs. (The federal government still pays 40-60% of the costs for woodwork beneficiaries.)

    Well it is about time!

    However– I do want to question one item in your excellent email.

    You state that Medicaid coverage will lead to less hospital bad debt, and therefore to lower health care costs overall.

    I do not think that is true. Per Jack Hadley and others, hospital bad debt is well under $30 billion a year after various federal revenues to hospitals are factored in.

    Even if this bad debt went to zero, I think that the effect on a $2.3 trillion national health care bill would be very small.

  26. I don’t want to have a pissing contest with anybody, but this post and comments thread is nearly half a year old and has become an exercise in ACA bashing vs ACA defense. Surely by now everybody should know the answer to that question is a mixed bag from state to state, region to region and from one insurer to the next. We are like those five blind men examining and describing an elephant.

    Meantime, here are a couple of items that have popped up in the last week or two that were news to me — and I’ve been paying attention since before ACA was crafted.

    ==> One in five Americans is now a Medicaid beneficiary.
    Not all this growth is due to Obamacare; it can’t account for the slight growth in Medicaid enrollment in that didn’t participate in the health law’s expansion. But it is possible the law had an indirect effect in those places. People who were already eligible for Medicaid, but not enrolled, for example, may have heard about the coverage expansion and explored their options.

    These signups by people who were already eligible for coverage are known in health policy circles as the woodwork effect. And it seems to be especially strong in some non-expansion states. For example, South Carolina, which has not expanded its Medicaid program, has seen enrollment rise by 14.4 percent anyway. Montana, another state opting out of Obamacare, has had 10.4 percent growth.

    ==> This shift/change is having an impact on costs and treatments.
    And it’s not just that people are signing up for Medicaid; they’re using it, and early indicators are that expanding access to healthcare is having the intended effect of reducing instances of uncompensated care. The Colorado Hospital Association released a study this week showing that “hospitals in states that chose to expand Medicaid under the Affordable Care Act saw significantly more Medicaid patients and a related reduction in self-pay and charity care cases.” Hospitals are obligated to treat and stabilize emergency room patients regardless of their insurance status or their ability to pay. If they can’t pay, the hospital gets stuck with the bill. Expanding the Medicaid rolls means that more people can seek out care and hospitals will have to absorb less bad debt, which could lead to lower healthcare costs overall.

    The popularity of expanded Medicaid sets it apart from the rest of the ACA, which is still broadly disliked. That niche popularity has opened up a narrow path for Democrats to take the offensive on Obamacare and put pressure on Republicans who oppose the expansion. Senate Democrats sent a letter this week to Republican governors in states that rejected expanded Medicaid urging them to “put politics aside and do the right thing in helping to expand Medicaid coverage to the millions of Americans who desperately need it.” Among the signatories to that letter were Sens. Kay Hagan, Mary Landrieu and Mark Begich, all of whom are facing tough reelection fights this cycle.

    It wasn’t long ago that the average American didn’t know the difference between Medicare and Medicaid.
    I bet that’s no longer the case.
    Keep calm and carry on.

  27. I agree with you completely. It takes a level of curiosity and empathy that many do not possess. Can you imagine what it’s been like for the working poor? I had a patient who made $10 an hour full-time and had a daughter and she wasn’t even eligible for the state subsidized policies (that weren’t so cheap– she wouldn’t have been able to afford the $400+ a month she would have had to pay). I wonder if they can do math. Let’s see 40 x $10 is $400 a week, $1600 a month to support herself and her child in Manhattan.

    I saw her for free because she deserved it. She was a good person who needed help. Fortunately, there are providers who do pro bono work and help but there are not enough of us. I always have at least one pro bono patient. It is an honor to be able to reach out to those less fortunate.

    I am happy to see the working poor insured. These people contribute to our economy, they take jobs most educated people simply would not take, and they pay taxes. They are not a drain on the state like those who don’t work at all. And most are simply doing their best, they are not cheapskates.

    Thank you for making the point, Bob.

  28. I wonder what state you are in. I am both a provider and a purchaser of an ACA policy and I have the opposite experience as you. In New York, BCBS is a hot mess. In the event you don’t know this, differing entities direct the Blue Cross insurers across the states so you’re essentially dealing with a different company than I am (most likely).

    As far as you saying I have no idea of what I’m speaking of, I wonder also how you come to this conclusion. As someone who has actually purchased a policy, I would think you would want to know, as an ACA supporter, the problems that people are having. This way, supporters of the ACA will know where the critics might be right and work to correct these issues. I find it fascinating how hostile you are and the tone you take is very similar to other supporters of the ACA. I also supported it and in theory still do HOWEVER it has its problems and the insurance companies are basically dictating how things are going.

    It is disappointing to find that supporters of this legislation are so hostile to anyone having problems. I thought you folks purported to be more compassionate than the Conservatives who didn’t support it but all someone has to do is say ACA isn’t perfect and that person is maligned in the most destructive manner possible. Why are you disinterested in actual experiences of purchasers? Asserting that I had “handouts” and didn’t pay anything before the ACA is absurd and wrong because I did pay for my own insurance and I did not get “handouts.” Yes, New York state helped to subsidize health insurance for sole proprietors however I pay taxes and so am entitled to some benefits from that. I work, mister. I contribute.

    Additionally, to make the claim that people are “not willing to pay for decent insurance” is unfair, untrue, and unwarranted. You must live on Mars because if you don’t know that health insurance costs have skyrocketed and individuals who work for themselves — as well as small businesses — have had a very difficult time purchasing health insurance policies at affordable prices, I can only draw the conclusion that you aren’t even on this planet. This is why we have had so many uninsured.

    I certainly do know what I speak of since I experienced the problems myself. Did you? Did you buy an ACA policy? No, you are financially fortunate enough to be able to afford better policies! Good for you! But to judge others for not being as wealthy as you is….to honest with you, I simply cannot find the words to describe my reaction to your harshness.

    A problem with many of the ACA policies across the states — and I invite you to do the research on this if you would be willing to actually know what YOU are speaking of — is that the networks are so narrow as to be non-existent. For example, in Manhattan, a very large borough, Blue Cross had only one existing pain management specialist. In the entire borough! I called the mere six they had listed but only one actually took the ACA insurance or existed. One lived in Poughkeepsie, two hours north of the city, one did not exist, and three denied taking the insurance. That left me with ONE pain management specialist to “choose” from.

    Prior to posting their updated list of providers (which no one could access on January 1st by the way and which I obtained via email from their representatives), Blue Cross had published a list of providers that was MUCH longer than the updated list. They intentionally made it appear that they had dozens of pain management specialists when the truth was they had only one as of January 1st. On January 1, the old list — which was wrong — was still posted on their website and guess what? Their representatives didn’t even know about its existence! It took them almost a month to take that list down.

    So, they provided a list of providers that they knew was inaccurate to sell their policies. Geez, I don’t know, that sounds illegal to me but then I could be that idiot you’re referring to, you know, the one who doesn’t know what she’s talking about.

    Perhaps you should have read this more closely rather than reacting in such an emotional and angry manner. Of course you have had problems with cheapskates but i would argue that’s not the issue here. Everyone has problems with cheapskates; you are not alone in this experience. Cheapskates exist who have insurance through their employers, through the government, and through the ACA. Are the 50% of our population who get health insurance through the government and don’t pay anything (or very much) for their insurance cheapskates too?!

    Enough said.

  29. I’m a medical provider and dealing with BCBS is pretty great. On the other hand, pretty much every other insurance company is terrible.

    BCBS is reasonably easy for us to work with. Their systems are out of date and cumbersome, but they pay their bills and we can operate our business and pay our expenses and employees.

    Aetna, Geha, Tricare, Cigna, United Healthcare, etc. are horrible. They don’t pay their bills. They refuse patient visits on a regular basis. They say they will pay and then don’t. I have a full time employee (about to hire a second) just to keep up with these companies.

    I’m really sick of patients who are not willing to pay for decent insurance or healthcare up front by investing in a good plan. BCBS is, in my opinion, a good plan. I have it for myself and my family. However, being a cheapskate by not paying for a decent insurance and then expiating me to cut your bills (I get regular requests, especially from Geha patients) is really annoying.

    To the person talking ACA, you have no idea what you are talking about. Sweeping generalizations on state-negotiated healthcare is just missing the issue entirely. I’m sorry you are unhappy that you aren’t getting the handouts you are used to under pre-ACA, but it’s time people actually paid for care. Fact is, state run healthcare works great in other countries.

  30. Collecting deductibles up front is probably necessary for providers, but it is a terrible and shameful development for patients.

    Most legislators and wealthy voters and Mediare enrollees have no idea of the economic nightmare faced by uninsured workers.

  31. The yelling helped in one respect — contacting the Health Department here in New York resulted in them contacting the insurance companies and then I was prioritized. I was able to get my specialist visits approved for three months with Blue Cross and problems were resolved quicker.

    Now, I switched to a less known plan than Blue Cross Blue Shield and have had a much better experience (I got two of my doctors back, two who were the most important). However, I am still left with seeing a primary care physician in a neighborhood filled with poor immigrants. That means that I can only go to these clinics or sole doctor’s offices wherein one has to sit and wait all day to see the doctor (because we have lower priority than even Medicaid patients I’m sad to say). What you should do is talk to the billing person/persons at your providers’ offices and ask them what their providers are taking because office staff still do not understand the ACA and often unintentionally misrepresent whether or not the providers are taking the plans.

    Making friends with my providers’ billing offices gave me the information I needed to get a better plan — and the plan I got was a plan geared towards the poor! It’s better than the Blue Cross Blue Shield plan. As far as I’m concerned, BCBS is a criminal organization and should be put out of business. They will NEVER get my business again. Their behavior is despicable. The new insurance company, Health First, is a much better company and has been much nicer to me. Their customer service actually exists whereas BCBS’s customer service is negligible at best, and their representatives either don’t know what’s going on or out and out lie to you.

    All of the so-called “benefits” of the ACA actually work against middle class consumers. For example, you can go three months without paying your premium and your coverage will still be intact. Awesome, you say? Well, not really because if someone decides not to pay at all, they’ll essentially get free health care for those three months and the providers have to eat their bills. How does that work for the middle class consumer who most likely will pay their bills? It doesn’t because providers don’t want to take the plans and risk not being paid for three months of work. Would you take the risk yourself?

    Also, the high deductibles are another reason that providers don’t want to take the ACA plans. Again, their fear is, and this is legitimate, that they won’t be paid. Now, I’m a provider myself and I always collect deductibles up front but it’s much easier for me to do so than for a hospital to do so in an emergency for example.

    And as Dan S. says, the networks are so narrowed that our quality of care is substantially reduced. Look, if you have access to 100 doctors and then only have access to 10 doctors, what do you think will happen to the quality of your care, particularly when those 10 doctors are those willing to sign up for a plan with not only the above risks but also who are willing to take lower payments?

    It’s a little known secret that ACA plans are seen as crappier than Medicaid! That means we’re paying out of our hard-earned income to be treated as poorer than the poor who pay absolutely nothing. Great, isn’t it?

    And for all of those people who say, well, someone has to fall through the cracks, I say, then YOU change places with me if you’re so willing to let hard working Americans fall through the cracks. YOU go through this nightmare and see how you feel about your country then. I have never felt so betrayed by the American government and the Democrats than I have of late. So little talk about the real problems middle class sole proprietors who were thrown to the wolves (the insurance companies) have faced. We don’t have money to pay them off so what do they care?

    The Democrats lost me after this. I guess you could say that karma is a bitch because I did support the ACA. And in theory I still do but what I cannot stand is the misinformation perpetrated by both those for and those against this law. Yes, something had to be done, but don’t lie to me, and don’t tell me, well, they’re politicians and politicians lie. That’s no excuse. None at all. Essentially, that means that we can all be corrupt, lie about what we’re doing in our jobs, misrepresent our achievements, mislead people into contracts whose terms are favorable only to corporate America…in others words, hmmm, let’s see, who is saying that America is in decline? Geez, I wonder why.

  32. did the yelling help? I’ ve had one foot out the door to do the same. I’ve called every doctor in my area, and on the list and the one they requested. whom ever answers the phones at the insurance company need to listen when people need help. They are totally clueless. understand nothing. and couldn’t care less. This bullshit is stressful. I I don’t know where to turn next. I NEED A DOCTOR AND I want someone to listen. I worked my whole life, very hard. don’t I deserve to live? My life is at a total standstill because of this. Can someone answer a prayer. a direction. I really have serious medical problems. And I cant get SSDI without a doctor to fill out the paper work. see its a domino effect. I don’t know, but if I don’t get help soon I won’t be here. thanks for listening. If anyone can help? Bobby can you pass this along Thanks Karan.

  33. Bottom line is that all exchange plans seem to have seriously narrowed networks. I had created a Whitehouse.gov petition to raise awareness of this serious problem. Please consider signing:


  34. Where are you living? Urgent care will help you in a crisis and if you need medications, they should be able to prescribe them. Since I am a therapist, if you’d like to talk, feel free to email me at bowles. alison@gmail.com. I’ll see what I can do to help (and I mean that with no charge). Humana has to help you in a crisis and they are supposed to have a certain number of providers to manage the load. I found contacting the Department of Health got the insurance companies moving!

  35. Hi folks,

    I am having the same issue with Humana. Their list of mental health providers seems to be mostly wrong or out of date phone numbers, the ones I have been able to connect to have waiting lists 5 months long, or so long they will not even put your name on the waiting list. I feel desperate and because my issue is with my mental health, I don’t have much stamina for this fight.

    Last time I called Humana, they encouraged me to get on the wait lists, saying that because there are so many new people buying coverage, healthcare providers are overwhelmed. This may be true, but fear I will lose my job soon without help, and it seems like if I am paying the premium I should be able to see someone. Does anyone have other ideas? Should I just go to urgent care as one person suggested? I wasn’t sure if they would be able to help for mental health issues. Any thoughts would be appreciated.

  36. Alison, I don’t think Bob Hertz is trying to be argumentative. He’s just pointing out a couple of differences between Canada and the US, both of which are factual. America’s founding mythology derives in no small part from ideals embodied in the Massachusetts Bay Colony. Those Puritans believed — very much like today’s privileged elite — that there is a supernatural connection between wealth and morality. If someone is rich it must be God’s reward for being a good person. The corollary, then, is that if someone is poor or comes from a poor family, then they are being supernaturally punished for sinful behavior, either by them or others in their family. The notion is underscored by a couple of biblical injunctions about hard work, that those who do not work shall not eat.

    A 2009 study by the British Journal of Medicine reveals a mathematical connection between mortality statistics and inequality. (T)hose who live in societies with a higher level of income inequality are at a greater risk for premature death.

    One of my Facebook friends in Italy suggested Maybe your government does it on purpose! If they took care of poor people, that would mean it would have to spend money. And that is a very touchy topic where you live. I pointed out to her an old aphorism: “Never attribute to malice that which is adequately explained by stupidity.”

    You are quite right to point out that monetary and labor policies have everything to do with our problems. But don’t imagine we haven’t had irrational behaviors from the start of the republic. As Churchill said, “You can always count on Americans to do the right thing – after they’ve tried everything else.”

  37. Where’s your evidence to back that one up? Slavery was quite some time ago. I have trouble believing current monetary and labor policies don’t have something to do with the current situation.

  38. this is a side issue, but Canada never had slavery, and only admits immigrants who can be employed.

    That in itself accounts for much if the difference in median incomes.

  39. Sarah:
    I know how you feel. Blue Cross “voluntarily” agreed to pay back three weeks worth of premium payments to all subscribers in New York state who had purchased as of 01/01/2014 because of all of their screwups. I switched to what had been a Medicaid based plan, HealthFirst, and managed to keep a couple of my doctors. I still do not have a primary care that I can go to who I trust. I kept my surgeon and my pain management doctor. I lost my neurologist and my opthalmologist and my podiatrist as well. Oh and my dermatologist.

    A couple of things come to mind. One is that supporters of the ACA have done it a great disservice by not being open to legitimate criticism and brushing off the problems of hard working people like you and me. I too supported the ACA as I just did not think it fair that half of the people in this country have access to government provided healthcare — through Medicare, Medicaid, and the VA — and the other half don’t. BUT, when I saw problems with the ACA and those problems also dramatically affected me, I didn’t behave as if those problems didn’t exist. I couldn’t afford to unlike the other supporters of the ACA who turned out to be the least kind-hearted and actually behaved — as you can see from this blog — with disdain, sarcasm, and downright character assassination. I have felt so betrayed by my party and its members that I have now left it. I am no longer a Democrat. I was a lifelong Democrat having been raised a Republican. Now I am Independent.

    The other thing that many ACA supporters don’t appreciate is how long it takes to find good doctors and the value of a 10-15 year relationship with one’s doctor. And then when one loses 5-6 doctors with whom one has had long-term relationships, and one is ill, they simply don’t appreciate how frightening this is and just how difficult it becomes to access care, particularly when one now has to go much farther to get care and has to pay twice as much. I live in New York City and whereas before my doctors were all at the 168th Street New York Presbyterian location, I have to go to the upper east side, a full hour away by subway and buses. I had a ten minute walk to my doctors; now over an hour and I still have to find many of these complete strangers.

    I completely understand how you feel. I have felt so hurt and so betrayed by members of my (former) party. I reached out to my local representatives and they were indifferent. Funny because these are the people who claimed to care that people have access to healthcare (along with many people on this blog).

    Sad, sad situation. I felt as if I had gone down the rabbit hole and I still do. The feelings of betrayal and helplessness and victimization are profound, aren’t they?

    I’m back to my home country when I turn 65. I’m not going to lose everything I’ve saved only to be bankrupted by the 20% I’m going to have to pay at that time when those who haven’t worked a day in their lives will have full coverage. This is a system? What exactly has changed besides three million more people getting free coverage while many of us pay twice as much?

    I’m going to “socialist” Canada where, by the way, the median income is twice as high as “capitalist” United States. Go figure.

  40. This same problem has been plaguing me too since January. Local doctors that were in the network before ACA are now dropping off rapidly. At present, there is not one doctor for general practice or for OB/GYN, the two kinds of doctors I need. The nearest doctor in our network is an hour away. So now we are paying for expensive insurance that we can’t use. I feel completely victimized by this government scam and powerless. We already had insurance before these laws were enforced. Now, we are forced to pay for lesser coverage at a 75% premium increase and all visits are out of pocket, because local doctors are bailing from Blue Cross’ network. I cannot express how much I hate this plan.

  41. That’s essentially what’s happened. They’ve sold this insurance and the number of providers they have is probably about 5%, if that, of what is being posted. Perhaps even 2%. When I finish my research, I’ll let you know.

  42. You’re probably right about this one. I have to say a few people are trying. Even the rep at the insurance company who is helping me is infuriated. At least an insurance company employee is angry about this.

  43. “Alison, did you expect us to do your leg work? Did you expect insider insurance strategies? If you actually looked at what your department of health did you’ll probably find they did not act as advocate but simply sent your information along to the insurance company for another look. I doubt the insurance company was not obeying strict application of the law, and it sounds like they applied an internal policy mechanism.
    Did you post here because you panicked and had not pursued this long enough yourself for a quick resolution? This blog is not a DIY forum.”

    First off, Peter, if you had read the comments above you will find that I did not know that my email to a blog was going to be publicized. I was informing whoever wrote the blog what was going on.

    And who said it was a DIY forum? That you’re implying I expected that is insulting enough. Clearly, I’ve been doing my own legwork, don’t you think by now?? Really?

    In fact, I’ve been working on this network problem for MONTHS now. I think the detail of my comments following my unexpected posting should tell you that I’ve been doing my homework.

    Of course I didn’t expect you to do my legwork! My point was that the indifference, apathy and lack of concern shown by some on this board is probably even a bigger problem that the BIG PROBLEM, people who need care and can’t get it. The indifference of the American population to this problem is why we’re in this mess right now. No Western country would accept 50 and 60 something year old working people with no health insurance. None of them.

    I still can’t get over the rudeness on this board. A person is simply having a problem and expressing frustration and the problem is not a little one. Why be so hostile?

  44. Empathy does not require statistical proof. So no body should submit their best wishes to you conditional on the extent of the problem.

    But the extent of the problem is important to ascertain. Because ACA is being compared to the systems before it, and will be compared to the systems after it. That public policy is not 100 % is a truism, there will always be losers (worthy of our deepest sympathies) from change.

    Accounts from people like you are necessary to define the extent of the problem, but not sufficient.

    The plural of anecdote is not data but data starts with multiple anecdotes.

  45. Granpappy (like the name)

    Med Chi = Medical and Chirurgical Society of Maryland = State Medical Society

    The incident you describe is impressive – hard to top.

    Reminds me of a scam that was going on in the ’90s where various “HMOs” wanted to charge a fee to “credential” you into their networks – and then not send you any patients. We told them to f#*k off.

    Frankly, I think the whole thing has to do with the haste in which the ACA was rolled out – without time to take care of the “back end” properly. And you know how important your back end is 😉

  46. Alison, did you expect us to do your leg work? Did you expect insider insurance strategies? If you actually looked at what your department of health did you’ll probably find they did not act as advocate but simply sent your information along to the insurance company for another look. I doubt the insurance company was not obeying strict application of the law, and it sounds like they applied an internal policy mechanism.

    Did you post here because you panicked and had not pursued this long enough yourself for a quick resolution? This blog is not a DIY forum. “Don’t expect too much” does not mean give up. Glad you got it resolved.

  47. I believe they have and these folks who keep saying this is just the same thing as what has happened before, with all due respect, I don’t think they know what they’re talking about. I have been a provider in New York City for four to five years now, and I have never seen anything like this. And, I have never had my own income so endangered by the way since many of my patients’ policies have had to change — and more will change — and I am losing patients I have seen for years. This is a lot more happening all at once. It is much more than what has happened in the past.

    I think you nailed it when you said that the ACA has taken their game to a new level. And the point is that if you’re concerned about your healthcare and the healthcare of other citizens, then be concerned! If you don’t care, then continue with these blase attitudes.

  48. Don’t expect too much, Peter? No way. I don’t accept this at all. I expect much more than they are doing and I will insist that they do so. Have you become so cynical that you’re just accepting that our government is now a plutocracy and that there’s nothing you can do about it?

    Fact is that going to the Department of Health has actually worked. Finally, this afternoon, I received two calls from Blue Cross after speaking with my pal Tony (of Blue Cross) at length a few times today.

    The first call was from a lovely woman who told me that regardless of whether or not my pain management doctor is in my network, they are going to approve a single case agreement. A single case agreement allows me to see this doctor indefinitely, to have him treated as an in-network provider whether he is or not, and so long as I have this policy.

    Another woman called and told me that they were going to approve the visit to my doctor tomorrow and that she was going to call the doctor’s office first thing in the morning to assure them that they would be paid. This would not have happened had I not gotten the Department of Health involved. It was the Department of Health that insisted that Blue Cross contact me and resolve this issue.

    The attitudes on this blog, the complacency, is shocking to me. Yeah, I’ve had to do a lot to get this but it’s an important victory. I need this doctor, he’s a good doctor (although I’m not sure now about his heart but that’s another story), he knows my case, and he knows me. There aren’t too many doctors in the city that do what he does.

    If I didn’t expect much, I wouldn’t have insisted on much.

    And you know, you, Peter and others didn’t actually respond with any helpful information (the headline asks what should I do??). Lots of opinions that had some merit, some not, but you showed little empathy, little concern, and an indifference that I find has been very common in this situation. That indifference was displayed by my doctors’ offices when they didn’t pay attention to the fact that they were not on the network database and yet they were telling patients that they were taking the ACA insurance. The indifference I encountered at Senator Adriano Espaillat’s office as well. And with that indifference came no accountability.

    I worked in a mental health clinic in New York City for many years. When a patient went to the state, you can be sure that the clinic didn’t like this and always changed their tune as a result. In fact, there were patients who knew their “rights” so well that they had the non-profit agencies scurrying to meet their every demand because they would go to the state and file complaints on a regular basis. The law says that these complaints all have to be investigated whether or not the complainant is working the system. It gave a developmentally disabled patient incredible power.

    So, my experience is that state government does, at times, do its job, and that if I expect it to enforce laws, they will. Perhaps New York state is different from the states you all live in but here, to some extent, patient’s rights are recognized and enforced.

  49. “the Med Chi”

    Not sure what you’re referring to there?

    ‘it seems that the ACA has “taken their game to a new level” ‘

    I don’t know about that.

    Two years ago, the largest insurer in the country told us that employees of the largest employer in our area wouldn’t receive their new insurance cards until late February. We were “instructed” to treat the patients without proof of insurance, while not collecting any co-pays or deductibles. Then, when the patients had received their cards, we could file the claims. When we responded that even if the patients had their cards, we still wouldn’t have the information needed to file the claims (it wasn’t being posted on-line either), we were told to fuck off.

    Are the ACA plans really taking it to a new level beyond that?

  50. I am a physician and have never received a communication from the Med Chi about this before.

    I understand that the insurance companies don’t do a very good job – and their penalty is – they don’t have to pay!

    Nevertheless it seems that the ACA has “taken their game to a new level”

  51. Not apologizing for the ACA at all, just pointing out that this is the same crappy service the insurers have been giving patients and physicians for years. Contrary to what the OP claims, this is just business as usual for them. We have networks that are being created and dissolved continuously, patients without insurance cards, physicians without fee schedules at the beginning of every year. Nothing new under the sun.

  52. It seems to me that “the doubters”/ACA apologists had two substantive responses to Alison’s complaints:

    1) What you (Alison) are complaining about is an isolated incident.

    Having seen the same problem raised in my state (Maryland), I doubt that Alison’s problems are isolated. In fact, prior posters have pointed out that even as the “front end” (getting people to sign up) of the ACA is improving, the “back end” (communication between ACA and Insurance Companies) is still not working properly.

    2) This is an “Insurance Problem” not an ACA problem.

    In the first place this ignores that fact that the ACA was designed to work through Insurance Companies. Rhetorical Question: If I recommend someone to do work for you and that person does a bad job do I just wash my hands of it?

    Secondly, one of the reason that the insurance companies are having problems is the delays in signup and back end problems of the ACA. How many delays of signup and payment did the Feds MANDATE over the objections of the insurers?

    Strictly an insurance problem? – keep dreaming you ACA apologists.

  53. The Obama administration is so dependent on insurance companies to complete the coverage expansion, that there is no administrative energy left to really regulate these companies on a federal level.

    And state regulation of insurers is notoriously uneven.

  54. “I finally did speak with this representative from Blue Cross this morning. The only reason she’s talking to me is because I went to the Department of Health and did a lot of yelling and finally got someone who could contact Blue Cross directly and insist that they deal with my grievance.”

    Modus Operandi pre ACA and post ACA.

    “I still get to expect my state government to enforce their laws”

    Your state government gets a lot of lobbying from insurance companies and they fund elections – don’t expect too much. There is value in an Insurance Commission but it’s mostly window dressing.

  55. I get what you’re saying but no, I didn’t expect the ACA to “muster” insurance companies. But what I’ve been trying to say is that the situation is even worse with these new policies and there are even more sick people not getting care. I will accept that in time this may change due to the ACA as sick people can now get policies, many of them having had policies when they were sick by the way (that was a sweet deal for the insurance companies, wasn’t it?). Employer provided health insurance insured the insurance companies against having to pay claims as they knew that when people got sick, they wouldn’t be able to continue to work in many cases and they would lose their policies.

    Again, you all say this is how it has been forever and I get that but I reject this division of the problem into labels “insurance problem” vs. “governance problem.” Listen, there has been mental health parity legislation is New York for many years and that legislation has been responsible for my patients being able to come and see me and to have the services covered. Whether you agree with mental health parity or not is not the point here; the point is that mental health parity, LEGISLATION, made a difference in terms of making it easier for patients to access mental health care. And the insurance companies do pay me promptly for my services. Yes, there is a problem with them not paying enough to mental health providers. But, if the networks were legislated and it could be seen by purchasers of health insurance that they only have three adolescent psychiatrists, for example, maybe people wouldn’t buy their policies and then the insurance companies would be forced to pay more to get these folks on board. But since they can essentially lie about their networks, and what I’ve been trying to say here is that the situation is WORSE now and people need help.

    Label it what you will but I think this is a false dichotomy and basically irrelevant. We should have more LAWS governing these guys and that is governance. For example, it should be against the law for insurance companies to publish networks that don’t exist and that they make NO effort to update. That is, at the least, false advertising. There’s such a thing as contract law. If they represent the network exists and they don’t even know if the providers on that list are actually providing services and they are intentionally keeping false information on the network list to make it look longer, that should be illegal, plain and simple. We should be able to sue them for breach of contract for example. .

    I took my contract law course many years ago but I know that this is essentially illegal. And class action lawsuits against these guys often result in, for example, United Health not being able to throw providers off of their network to save money, as happened recently in a nearby state, I believe it was Connecticut. The court prevented United Health from making their network narrower and interfering with the doctor-patient relationship. I know that United Health and other major insurers were sued many years ago for underpaying out of network providers and they were forced to change how they were calculating payments. Again, this was done through the courts applying laws that already exist. So, where is the enforcement?

    I filed a complaint against BCBS with the Better Business Bureau and I stated that I wanted them to provide an accurate network list. I may continue to advocate and go to Albany and insist that this change. I’m sick and tired of this and I do not accept it just because it’s been going on for years. I know it’s been going on for years folks; I’ve just gone through eight years of care for my injured back, finally having it fixed (I hope) through nuts and bolts (made of titanium apparently and stronger than my original spine which was essentially collapsing). You think I don’t know this has been going on for years? That’s beside the point. It shouldn’t have been going on for years!

    And perhaps I will become an activist to make these laws happen. I refuse to accept that now with the ACA, things will be even worse. Okay, I accept that the networks will be narrower (I think; I reserve judgment until I know more about just how narrow they are). What I don’t accept is that I call ten providers on their list and those 10 providers don’t exist.

    I finally did speak with this representative from Blue Cross this morning. The only reason she’s talking to me is because I went to the Department of Health and did a lot of yelling and finally got someone who could contact Blue Cross directly and insist that they deal with my grievance. So, the state does have a role since they regulate these policies and companies.

    I do have a right to expect, given the representations made by the President as well as the Democratic party, that they help us with problems as the ACA is implemented. And given that I have that expectation, the department of health is working with me as they should. If I listened to the people on this list, I would not have fought so hard to get government involved and I would not be talking to Blue Cross at all because it is still impossible to get through on their toll free number.

    We get to go to the state to appeal insurance company decisions all the time. So, this is both an “insurance problem” and a “governance problem.” Both parties are involved and both parties are responsible to ensure that covered services are provided. So, these labels are irrelevant.

    My complaint with the ACA is how it’s been implemented and how it’s been communicated to the public and fundamentally misrepresented. In principle, I support health insurance for all given the current situation. But our President lied to us and we get to be pissed about that. We also get to challenge what’s happening.

    I appreciate your comment. I do get what you’re saying about “forcing people into the waiting clutches of the insurance industry.” But again, regardless, I still get to expect my state government to enforce their laws, to pay attention to the complaints we file, and I get to expect the insurance companies to pay for coverage. If I didn’t expect that, I would not have gotten the care I needed all these years.

  56. “If you’re “accepting” that the ACA was supposed to muster insurance companies into doing the right thing for each individual policyholder you’re been deceived. The ACA’s purpose was to legislate a bunch of uninsured people into the waiting clutches of the insurance industry – subsidies or not.”

    AHIPcare. Meet to the new boss, same as the old boss.

  57. “If anyone is being dramatic here, it’s you by jumping to all these conclusions with nothing to back them up”

    Really’ eh? By simply questioning the legitimacy of this post at the outset? I wasn’t the only one.

    OK, I apologize. 😉 You have an insurance problem. Welcome to the club. Everyone has their horror stories. These pre-date the PPACA. They will not be materially abated by the PPACA either. We’re addicted to our no-value-adding hypercomplexity.

  58. “I don’t agree that this is only an insurance company problem, it’s also a governance problem because they are not supposed to be in the business of “not paying for treatment.” That’s what we’ve all come to accept.”

    I’ve read all the comments and never doubted the authenticity of the poster’s experience.

    If you’re “accepting” that the ACA was supposed to muster insurance companies into doing the right thing for each individual policyholder you’re been deceived. The ACA’s purpose was to legislate a bunch of uninsured people into the waiting clutches of the insurance industry – subsidies or not.

    This IS an insurance problem and I believe insurance companies have for years been abusing individual non-group policy holders – it’s just too easy for them not to, and save a little money.

    Once I was insured as an individual with BCBS for several years. I tried to process a small claim (my first) which went unpaid for several weeks. On attempting to get it processed several more times BCBS claimed they lost the paperwork 3 times. I was always the one phoning them while they remained unresponsive. Even a registered letter with my claim information did not get them to act. In one conversation with a customer service person, who risked her job, I was told BCBS, “does this all the time”. It was finally resolved with some (not much) help from my state insurance commission with BCBS making false statements about what transpired.

  59. Drama? Laughing at you and your paranoia here is drama? Hey, call the police, someone is posting anonymously and that person must be lying to us!!!

    You are not a nice person. Just by seeing your posts here, I don’t know if you realize that you are being very insulting. I haven’t posted BS (?) — you didn’t have the courage to say what you meant here or perhaps it is not allowed so you are skirting the rules by using this abbreviation to hurl an epithet at me?

    If you read the responses I posted above and my guess is since you don’t seem to be interested in facts, you probably haven’t, but I am not the one who put the contents of my email on the webpage anonymously (but again, I appreciate that someone in the media paid attention to my complaint because no one else has).

    If anyone is being dramatic here, it’s you by jumping to all these conclusions with nothing to back them up. Honestly, I don’t get it. What’s your problem? I didn’t say my name? No, the staffer at this blog didn’t say my name so I guess that’s the person must be a liar based on your logic?

    I wasn’t looking for “props” but a little empathy. Even more important, I want people to know this is happening because I expect it’s going to go on and will happen to people who are much sicker than me and I happen to care about that. Look, you can see it’s clear I can fight for myself but others can’t. I care about them; I should hope you do too.

    Did you even consider that an individual might want to tell you all something — and others — and not reveal their personal information because that person might be afraid of a huge corporate entity? It wouldn’t make what that person had to say any less true and the fact is just because I’ve said my name, it doesn’t make me any more or less credible than if I didn’t. I mean, what are you going to do? Look on the internet and find me and see if I exist? And then? Then you’d give me “props” would you?

    Since I’m not afraid, I’ve reported BCBS everywhere as everyone should because if they did — and they were as verbose as I am — maybe someone WOULD actually do something rather than insult a person who is trying to tell you something that is important.

    This is not the same situation as every January when insurance policies are renewed BECAUSE most of these insurance companies are creating new networks and those networks, as published, are nowhere near accurate. We have no way of knowing what doctors actually are in these networks unless we personally go through every name on the list to find out. That’s not my job, that’s BCBS’s job because they’ve sold these networks — with the government’s assistance, I might add — and represented that they exist.

    My question is how long is this going to go on? It’s not an issue of people only having trouble the first few weeks of the year but perhaps even months or the entire year or forever if most people are the likes of you and aren’t paying attention to what is being said but to superficial data.

    Pay attention, Bobby Gladd, pay attention to what’s important. My name isn’t important; what is happening to sick Americans is.

  60. Hi THCBist aka Alison,

    Glad to be of help. Regarding your referral, I don’t see how they can refuse if it comes from an in-network urgent care or ER provider. But they spend a lot of time thinking up weird rules for this sort of thing, so maybe. I would definitely call the neuro first — he seems like a decent person, and I am sure you are not the first patient of his to have this sort of problem.

    I’ve been blogging about this sort of thing for more than five years.
    I’m not old enough to remember when insurers were reliable — I’ve only been sick 20 years — so I don’t know why this business isn’t common knowledge. The ACA is definitely a mixed blessing in that respect.

    THCB doesn’t notify commenters when there has been a reply; I just happened to check this post again from somebody’s FB feed. Shoot me an email if there’s anything else I can do: dx (at) duncancross.net

  61. Finally, a lovely person. I would do that if I could but I need a primary care and they assigned one who is out of town until the third week in January. And, I can’t get through to Blue Cross to find a solution.

    My understanding is that only the PCP can do the referral. Without the PCP, I’m screwed for now. The reason it’s scary and upsetting is that I am on medications I cannot run out of.

    The only thing I can think of right now is to call my neurosurgeon and ask him to help me. He’s the sort that promised care even if I lose my insurance. This isn’t quite the same situation but I imagine given his previous offer, he’d probably be amenable. He doesn’t want $220-$350 to walk in the door. I could pay it, my friends, but then how do I get it back? I’ve paid a premium for the month of January; why should I have to pay to see my doctor?

    This makes me angry. I don’t agree that this is only an insurance company problem, it’s also a governance problem because they are not supposed to be in the business of “not paying for treatment.” That’s what we’ve all come to accept. When one buys insurance, until the last couple of decades, one actually expected that their policies would be paid out when they needed them to and the health insurance usually did. At least, that was my experience with the policies I purchased myself when I was a kitten. Remember the good old days when we had percentages to pay and everything was clear? I miss the days when no one knew what an HMO or PPO was.

    If I wrote that my husband died and the insurance company was refusing to pay the claim for no good reason, who would accept that? Would any of you? No, of course not. So why accept that they’re making it so difficult for us to obtain care? Why would anyone accept this? I’m not asking for the moon. I’m asking for one doctor’s appointment and a few cheap medications. It’s not rocket science, is it?

    Tell me, Duncan, what am I missing here?

    It’s not just this situation though, Duncan, that’s been so upsetting.

    Perhaps since I was only in a bus accident many years ago and didn’t have any other illnesses, I was complacent too and didn’t know just how hard it was for the sick to get care. The scary thing is that there are so many sick people out there who are not able to advocate for themselves because they’re, duh, sick, and if we don’t do it, who will? They’re not able to. It shouldn’t be made this hard. I can agree that insurance companies might have to set limits but to deliberately deny care or to find ways around providing care is bad faith at the least.

    I’ve only had back problems. What frightens me, folks, is if I get something worse. I really couldn’t tell you that I would be able to tolerate the difficulties that I have had with getting care for a back injury (that occurred through no fault of my own so the “you’re sick because you made it so” blamers can forget that line). Imagine trying to fight these companies when you’re undergoing chemo and radiation.

    Be afraid. Be very afraid. I hope none of you are ill now or have to face it in the future but I am afraid and I’m not happy with the system either under the ACA or before. I get why it happened.

  62. Thank you, Alison, for this. Let bygones be bygones and we can forget there was ever a problem. After fifteen years of internet activity this is almost a non-event for me.

    As for the anonymity business, years ago when the Web was like the wild, wild West, nobody wanted to reveal their name. There were good reasons for that, too, not the least of which was making yourself vulnerable to anyone who wanted to do something bad, like a vindictive boss or co-worker looking for dirt. I cut my teeth on a Yahoo message board which only used screen names. Nobody used real names unless they were famous, and sometimes not even then, until Myspace and Facebook came along.

    I realized early on that on the Web no one has any credibility unless they become real to others. Even with a screen name, over time if someone is consistent, reliable and predictable, even if they don’t always make sense, at least they have some measure of credibility. The Health Care Blog has a community of commenters who have been doing this stuff for years. And even those with whom we disagree have a place in the order of things. Newcomers are always welcome, but because of the volume of spam, marketers and writers with various agendas this community is no different from any other. We may seem like strangers to a newbie, but most of us know each other and are not surprised at anything we see. My name and a few others are also hyperlinks to our blogs or home pages, so that will give you some idea who’s posting and commenting here.

    Whatever happens with your appointment and insurance problems, feel free to come again to participate. This site and a handful of others are a rich source of information. Check the links in the sidebar and prepare to be overwhelmed. (And next time you comment, feel free to call yourself Alison, or whatever strikes your imagination, to avoid confusion. Anything but THCBIST. When we see THCBIST we know it’s someone on staff here tossing out some red meat.)

  63. Dude, Oxford paid the big expenses. Perhaps I was a bad customer last year but I’ll be a good customer for Blue Cross because all they have to do now is pay for a monthly doctor visit and medications that are not that expensive. The expensive stuff happened with the surgery. Nerve damage is not treated with expensive tests.

    Other than this, I’m completely healthy so I don’t think they’ll be spending a lot of money on me.

  64. It’s not that “private” Mr. Wilson. If it were, the government would not be involved in selling the policies. Come on now. If you’ll see the results of my research above — and I did a lot of research to try to avoid this problem in New York state — you’ll see that this has not only been the fault of the insurance companies but also the rollout of these plans. When I said “ACA plan,” I meant a plan that was created due to the ACA and was sold to me through New York State. Private? Well, I don’t know about that.

  65. Well, look, I think that it’s probably a bit of both but I didn’t write to the blog complaining of this problem to assign more blame to the ACA than to Blue Cross or to Blue Cross rather than the ACA. I think the ACA rollout has been disastrous AND that insurance companies have always been irresponsible and unresponsive to consumers.

    As a provider, I have seen that it is very common for insurance companies to delay getting identification cards to members in the first month of coverage but I do believe that this is no accident. They do not have to provide coverage because members can’t use their insurance as it’s hard to make appointments without the identification number. Imagine the money they save for each person and then multiply that by millions. It’s a cost saving measure, nothing more, nothing less. .

    I disagree with your assertion that this has “always been a nightmare for patients, doctors, and pharmacists” in January of every year. I’ve had patients change policies and it happens at all times throughout the year, not only in January, and the only “nightmare” as you call it is usually the delay for the patients in getting their ID cards. Other than that, not much changes as the networks usually remain the same. Entirely new networks are not being created by the insurance companies every year. New policies but not new networks.

    I don’t think you can pin this entirely on Blue Cross as they didn’t even know of my existence until December 14th. I purchased the policy as soon as I could get on the website and get a rep on the line and that was well into November. I tried the entire month of October and couldn’t get through or I could and the system wasn’t working. This is the ACA and it’s rollout, not the insurance companies.

    What I can pin on both our administration AND on Blue Cross is this idea that these networks didn’t have to be created until now. Blue Cross claims to have been sending contracts out to their, it should be noted, already existing providers in the spring of this year. None of my doctors received anything until very late and no one knew if they were even in the networks. My guess is this is the insurance companies taking advantage of the confusion to drag their heals and the administration changing all kinds of things so that it was difficult for the insurance companies to get stuff done.

    This has been the complaint of the website developers in almost all cases, not only of insurance companies and providers.

    I’ll leave it at that. You’re a little too indifferent about my plight for me to want to say more. It’s scarier than shit, let me tell you. I’d love for you to be in my shoes right now.

  66. Dude, not looking for props from you. And again, why do you care what my name is? Are you planning to give me a call?! LOL! You guys are funny.

  67. Sorry, John, for the confusion. This is what happened. I wrote to the blog in an email and they posted my email. I didn’t know they were going to do that (but I did appreciate it). Then, I saw the THCBIST at the beginning and thought that for some reason, they were referring to me by that name (for what reason, I didn’t know but I figured I would go along with the “name” they gave me).

    I don’t know that it’s important that I reveal my name although I’m happy to do so (Alison). Would it actually matter if the post was anonymous or not? I mean sometimes people don’t want to identify themselves. That wouldn’t mean the individual is not being truthful.

    I didn’t call you all those names and I do appreciate your thoughtful response. Your response along with the other three seemed so unsupportive that I was a little shocked. The very quick, dismissive nature of the posts was surprising. I mean, why would I lie? And why would I take the time to tell anyone about this if I was lying? And who could make this stuff up in such detail anyway?

    I still do not have my appointment. I received one call from Blue Cross today at 2:30 pm while I was on the phone and yes, on hold, dealing with another insurance matter (for a patient). I did get a call back number this time and called back twice but she did not pick up. You can imagine that I will call hourly once I am up in the morning. Had she left a number on Friday when she called at 8:55 am, I would have had the entire day to call her. I do have to work after all and it’s been hours and hours of my time trying to get through to them (I would say I’ve been on hold for 10-15 hours altogether since 12/23/13).

    No one has answered the question of how I am to see my doctor without a referral and since the Blue Cross rep only left her name and number today at 2:30 pm, it doesn’t give me much time to resolve the matter. My guess is that I will not be seeing my doctor on Wednesday but we can always hope. I don’t know what the representative will say to me.

    I have found insurance companies to be very rule oriented and not inclined to be helpful in cases where it’s difficult to obtain a referral. They usually say that it’s the primary care physician’s responsibility and they may refuse to allow it despite these circumstances. There’s no telling.

    I will keep you in the loop if that’s helpful.

    Funny people are so concerned with what my name is. I could give you any name! It’s the internet! As I said, the blog posted initial complaint anonymously, not me.

  68. The author has my deepest sympathies, but I agree with other commenters that this is an insurance problem, not a governance problem. Insurers are in the business of not paying for treatment; shuffling a pricey patient around is a well-established tactic. If there is an in-network urgent care facility (or ER) that’s convenient, you might go there for the referral. The co-pay is probably a bit higher, but it will save you from paying the specialist’s visit out-of-pocket. I end up using that trick every couple of years or so.

  69. Thanks, staff member, for your clarification and feedback. I promise to be more careful about how I pick my words. I’ve been accused of many things, but never that.
    Thanks, too, to others who resisted jumping on the wagon.

  70. “Insurance companies make money on the people who never even hit the deductible.”

    Yep. I’m now in a high-deductible PPO ($1700/$3400) thru my wife’s employer. I’m a moderately complex 99213. I see my doc twice a year, labs (UA and blood panels) once a year, on a couple of the usual maintenance meds. I don’t even come close. It’s all OOP for my wife and I. It’s all profit for my insuror. My insurors been making bank on me for many years.

  71. From an insurance company’s point of view, people like TCHBIST are bad customers. People who see a specialist on a regular basis are of course far more likely to need expensive tests and maybe hospitalization in the future.
    (and as we see from this post, maybe in the very near future)

    Insurance companies make money on the people who never even hit the deductible.

    I think this is a main reason for the carelessness that the companies show about networks. If this policyholder gets really frustrated, maybe he will go elsewhere at the next open enrollment period.

    Of course the confusion and rule changes of the ACA rollout have preoccupied the insurers. They have put all their effort into filing products and initial enrollments.

    But over the long run, the incentives to give lousy service to sick people will remain.

  72. @ John Ballard

    Apology accepted. You might want to pick your words a little more carefully in the future though. To clarify, THCBist is a THCB staffer. The reader misunderstood and posted under the , causing a bit of confusion.

    @ THCB Reader in New York

    Your comments have been relabeled as posted by @THCB NYC. Feel free to change to anything you feel is more appropriate. If you have trouble doing this, email us and we’ll do it for you.

    @ Tom Wilson. Maybe. Maybe not. On the other hand, the government should be responsible for managing the marketplace. It sounds like action may or may not be necessary here (as you indicate, a degree of confusion was inevitable), but this is certainly a story to keep an eye on.

  73. This is a problem with the insurance company. I don’t know why this needs to be pointed out, there is no such thing as an ‘ACA plan.” It is a private insurance plan, and I have also had problems with the insurance companies not being prepared. They would love to deflect blame onto the government, the fact is, this is an insurance company problem and is not new. The only new thing is more people are talking about it. All my life I thought this sort of doctor network problem was just standard operating procedure, something we all had to tolerate. Only since the ACA took effect do I realize that it’s something to complain about. So good for Obama for pushing the system to improve.

    For what it’s worth, I had a hell of a time trying to get through to Blue Shield California, while CoveredCA got in touch with me to make sure I was on track to be covered January 1st.

  74. This is a Blue Cross problem, not an ACA problem, and you can’t expect government agencies to be of any help in solving it.

    This is a very common problem at the beginning of the year for many insurance plans. January has always been a nightmare for patients, doctors, and pharmacists, and the ACA has nothing to do with it.

  75. “central planning works comrade!”

    LOL. Yeah, “central planning” in this case being the byzantine opaque policies being marketed by 6 gazillion private for-profit AHIP member insurance companies via the HIXs.


    Happy New Year, btw.

  76. I’m sorry for seeming, as another comment says, callous, dismissive, insulting, and uncaring. My aim was not to insult anyone but to find clarity in a very opaque picture. Combing through the Web is never an easy task because it is such a mechanical exercise, especially when a living person is easier to talk with. (Even if an internet search turns up an actual telephone number there is often still many menu layers to navigate before a real person is available. And he or she is still there to screen out all but the most persistent calls.)

    That first line in the post may have thrown me off — A THCB Reader in New York City writes in to say – followed by a group of paragraphs, the first of which opens with a quotation mark. But the close-quote mark does not appear until the very last paragraph, following three dots. This leads me to believe that THCBIST is someone on staff at The Health Care Blog, which makes sense if anonymity of the writer is the intent.

    Omitting the usual quotation marks at the opening of succeeding paragraphs is an understandable mistake, but that’s not as confusing as now, when the same “THCBIST” appears to be speaking in the first person as the writer of the original writer.

    So to both of you, anonymous writer and staff representative, please accept my apology for what I wrote. I don’t think I ever got such a response from seventy-some words.

    If the blog administrator wants to delete my comment as offensive I have no objections. Please do so and end this acrimonious exchange. I have left comments at this site for several years, am not anonymous in any way, and hope not to be banned from further participation in these comment threads.

    This comment as “THCBIST” includes “Did I really sound crazy? I must confess I sent an email to the blog and didn’t realize…” This construction suggests the original writer, not someone on the blog staff, is speaking. I want to offer some constructive suggestion how best to resolve your problem, but I am at a loss. I have none. It seems you have done all your due diligence and more and have met with nothing but frustration at every turn. It was not mentioned, but I presume you already did the obvious, calling the office managers of both your PCP and pain management doctors seeking help from their ends.

    I ran into a similar situation a few years ago, long before ACA was even discussed, when I was improperly referred to a specialist who was “out of network” and that mistake was not discovered until two appointments and many hundreds of dollars later. I discovered at the time that the group sponsor actually had a committee that met weekly to resolve such problems, a kind of in-house arbitration committee, and they decided to pay for the appointments made by mistake and have me find another in-network doctor. Luckily the problem had started to resolve by then and I was able to forget the problem for a few more years.

    I hope you get this resolved by Wednesday, your next appointment mentioned in the comment. If not, perhaps your specialist and his or her office manager can get their heads together and help solve your problem. Plan B might be considering a referral by the specialist to a colleague who can meet your needs.

    If nothing else, this case illustrates the byzantine complexity of a health care system in bad need of revision. I am on record repeatedly as giving ACA only the most grudging encouragement, a piece of legislative sausage-making crafted mostly by the insurance lobbies, having little or nothing to do with health care. But that’s the best that can be done with the federal system we have in place.

    Whoever you are, I wish you the best and hope you are soon able to resolve the problems you have described.

  77. Wow, John Ballard. Let’s hope that you never have to face someone as callous, dismissive, insulting, and uncaring as you.

    “Is this a medical problem or an insurance problem?” you ask. The answer is self-evident to anyone who reads “this anonymous complaint.” It is both. THCBIST has a medical issue that needs treatment. He can’t get his treatment covered by insurance, because of a Catch-22 that no one in authority cares about.

    You top it off by attempting to smear THCBIST by implying that he’s imagining everything.

    So it this what it comes down to, Mr. Ballard? I honestly hope you don’t find yourself in THCBIST’s predicment. But if you do, please rte-read your reprehensible comment here before daring to ask for anyone’s help or sympathy.

  78. THCBIST,

    I believe you.

    I have no trouble believing that the various insurance companies and governmental agencies, in their rush to get things done, haven’t figured out which docs are actually participating and which aren’t. In fact, I would have predicted it.

    You can add this problem to; the sign up problems that seem to be improving, the lack of payment of some that have been signed up, the age and sickness distribution of those that have signed up (the death spiral) and probably several other problems that weren’t anticipated.

    But don’t worry – central planning works comrade!

  79. Please refer to my responses to John Ballard and Saurabh Jha above as this response does not merit further explanation. If asserts little facts, if any, and proves nothing.

  80. Please see response to John Ballard above.

    That this is happening to one person should tell you that it will happen to others who attempt to obtain referrals for any provider who has agreed to be in Blue Cross’ new ACA network and who hasn’t yet been placed in Blue Cross’ database. Now, if the provider is in the network AND in the database, then members won’t have problems but given that it is not clear when Blue Cross intends to update this database and that their published list is dated November 21, 2013 the question remains when can we expect them to?

    Another tidbit you should be aware of is that many of my providers only learned within the last week or so that they were in the networks and even then it wasn’t and isn’t completely clear to them because Blue Cross has not made it clear. They did not mail contracts to their providers in the spring of 2013 as they have asserted or, if they did, it wasn’t to my providers. I asked many providers in the last few months of the year as it was my concern, and almost all of the providers had no idea.

    The providers at New York Presbyterian (the Columbia University location on 168th Street in upper Manhattan) did not even know as of the third week in December. I checked with hospital staff and I was told either that they were still trying to decide or that it was still being negotiated. Thus, the actual networks are still being put into place rather than having been already put into place as we might, in a perfect world, expect.

    Why would it be happening in New York state and nowhere else? I would venture to guess that it’s happening everywhere because if we can count on anything, it’s for insurance companies to keep things confusing and obscure AND difficult. Anyone who has been sick knows this. Only those who haven’t been ill do not.

    Additionally, I challenge you to call providers on the list of network providers link that I provided above and see how many you can reach. I called a pain management doctor’s office, or so I thought, only to find out it was a men’s locker room. Perhaps I should have asked where in case it was the locker room in my doctor’s office?

    And I might also add that if any human being complains of a problem, how relevant is it the number of people it happens to? Isn’t it relevant if it is happening to one?

    And how might you know how many people it’s happening to if you don’t listen to those who are informing you of the problem?

  81. I had to laugh at this response. First of all, I can assure Mr. Ballard that this is not a medical OR a psychiatric problem (although it could be soon if no one does anything about this). Perhaps I did not express myself clearly enough such that the “she must either be sick or crazy or both” response is truly being made innocently.

    Simply because Mr. Ballard provides the audience of this blog with a link to a website that discusses Obamacare horror stories does not mean that he has proven his point. In fact, it doesn’t prove anything at all.

    I can assure you that I spoke with a New York state Health Department employee for over an hour last Thursday while we both attempted to find my doctors on that list because she did understand the problem (and she should given that she works for the department of health; Mr. Ballard has an excuse for not understanding and that can only be blamed on ignorance).

    Perhaps John has not had the misfortune of being in one of Blue Cross’s HMO networks. John, please click on the link below:


    You will see the following text: “Alert! We’re updating the list of network doctors for New York HMO plans on the Exchange. Please use this list to view the doctors in-network, instead of our Find a Doctor online search tool.”

    If you click on that link, you will find yourself at a 2000 plus page list of doctors. You will note in the upper right hand corner that the list is dated 11/21/2013. How can it have been updated recently if it is dated November 21, 2013? I can assure you it hasn’t changed because I have checking it since then.

    If you go back to the first link, you will see that there is a “Find a Doctor” search available to Blue Cross members. If you attempt to look for a doctor, you will find that you can look in your own network and that there is a list of 14 networks in New York. The ACA plan network for individuals in is called “Pathway X Enhanced/Individual via Exchange.” You can see this for yourself if you click on “I want to search by selecting a plan” and review the list of Blue Cross’ New York networks. Then, one can choose between either the bronze, silver, gold, or platinum plans (I have, by the way, chosen a platinum plan due to my medical, not psychiatric, problems). I might add that even if I had psychiatric problems, this would not mean that this complaint stems from same. I have to wonder, John, does this mean that any person who is diagnosed with a mental illness is not to be believed if he or she also has the same problem I am having?

    As I stated above, two of the doctors I am looking to see cannot be found in the ACA network (my primary care, who can be found in other networks, and my pain management specialist, who cannot be found in ANY networks at all even though he takes not only Blue Cross but my specific plan as well, unless Mr. Ballard knows better than my doctor and his staff).

    I can go to see the primary care Blue Cross assigned me even though I didn’t choose him but WAIT! I can’t because he’s on vacation until January 21st. And my specialist appointment is on January 15th. So, unless we can bend time, I can’t get a referral from my primary care now, can I? Not the one assigned to me nor the one of my choice. And since I had no ID number until last Thursday, I couldn’t have made an appointment sooner anyway because I would not have been able to find my primary care assignment nor would anyone talk to me without at the least an ID number. I also need, in the case of Blue Cross, a referral.

    Did I really sound crazy? I must confess I sent an email to the blog and didn’t realize my desperate complaint would be published but perhaps Mr. Ballard’s response can also be explained by the fact that what I’ve described SOUNDS crazy, doesn’t it?

    I read over my complaint and I can’t say that I sound like a psychiatric patient. Perhaps because I said “it’s driving me crazy,” Mr. Ballard assumed I was already there? I am perplexed as to the basis and logic of his response.

    In the event the reader is wondering, I have been a supporter of President Obama’s both times running and I supported health insurance for all if not only because half of the country was already getting it at the taxpayer’s expense and I happen to be one of those taxpayers. Individual health care policies in New York state started at $1500 per month for an HMO and up. How many individuals could pay that amount? It simply did not seem fair that some people were getting health insurance at the expense of others (and I am not speaking of those who have paid into the system here but those who have not).

    But that is neither here nor there because regardless of whether or not I supported Obamacare, the facts are as I have stated them. I could go on here but I do believe I have made my point should anyone care to investigate.

  82. This is a spoof. Has to be. Like the YouTube of Spielberg announcing that Daniel Day Lewis will play Obama in his upcoming movie “Obama.”

  83. One has to assume this a true account (onus probandi).

    Hardly surprising that a well orchestrated planned roll out of exchanges is not flawless.

    The relevant question is not “is it happening?”, but “to how many?”

  84. Something about this anonymous complaint doesn’t pass the smell test. For one thing, is this a medical problem or an insurance problem? It’s important not to confuse one with the other (as this self-described “self employed psychotherapist” should know).
    Listen to this short podcast:

    [There is a chance this may be a problem of psychiatric origin, but that can be ruled out because a psychotherapist should know.]