Provider network problems in Nevada Health CO-OP frustrate consumers

Lenora Kaplan discovered by accident that her health insurance plan was broken.

Now, Kaplan is urging other consumers to look twice at their new, Obamacare-compliant coverage before they try to use it.

Kaplan, a businesswoman who runs a local marketing and media-training company, bought her policy in mid-December via the new Silver State Health Insurance Exchange. Her main requirement while plan-shopping? That the three doctors she sees for routine care were in the provider network. She thought she’d found just the coverage through Nevada Health CO-OP, a new, nonprofit insurer that listed her existing doctors in its network.

But when Kaplan asked the CO-OP last week for a new list so she could find an internist, the updated version they sent her didn’t have any of her doctors on it. Kaplan called to ask why, and said she was told that doctors can opt out of a network at any time.

“I’m paying $388 (in monthly premiums) for a plan that none of my doctors are in. Now I need to know what to do,” she said.

The CO-OP released a wide-ranging statement late Monday that blamed the state exchange’s website, Nevada Health Link, for its woes, though the insurer’s comments focused on not getting “full membership information” from the exchange, rather than explaining why it’s having network problems. The statement did say that provider networks “sometimes change as both insurers and doctors make changes to their practice.” It added that it updates its local, 2,000-provider directory weekly to stay current on network changes, and said members should check its website rather than www.nevadahealthlink.com for network details.

But the CO-OP’s problems seem to affect only it. Neither Anthem nor UnitedHealthcare, the other two carriers selling in Southern Nevada through the state exchange, are having network problems, said Frank Nolimal, an employee benefits adviser with Las Vegas insurance brokerage Assurance Ltd.

And CJ Bawden, a spokesman for the Silver State Health Insurance Exchange, said early Monday that insurers such as the CO-OP contract with doctor networks separately from the exchange, which is just a marketplace through which carriers sell coverage. The exchange posts provider directories online as they get them from insurers, he said.

Regardless of how or why they’re happening, the network issues are causing big headaches for consumers. Kaplan said she decided to share her plight because she doesn’t want others to be surprised when they go to the doctor’s office. At 53, she’s a long-time buyer of individual insurance and a savvy, experienced health-care user. Consumers who are experiencing their first go-round with buying and using a plan need a heads-up, she said.

“People who finally got through all of the exchange’s website issues think they’re covered by the doctors they go to,” she said. “They (the CO-OP) have to come out and say to people, ‘The physicians you signed up for may not accept this insurance.’ Otherwise, it’s just false advertising.”

It wasn’t supposed to be this way for the CO-OP, part of a relatively simple concept added to the Affordable Care Act to create consumer-driven, locally based health plans for state insurance exchanges. The Nevada Health CO-OP has three sponsors: the Culinary Local 226’s Health Fund; its national parent, UNITE HERE Health; and the Health Services Coalition, a local consumer-advocacy group that negotiates health care costs and tracks quality of care for more than 300,000 members employed through cities, unions and major companies.

The sponsors won the federal contract — and $65.9 million in federal startup loans — in May 2012. CO-OP officials planned to double up on the Culinary’s existing, extensive provider networks.

It’s not always working that way in practice, though CO-OP officials said in their statement that the nonprofit has already covered office visits, prescriptions, procedures and hospitalizations, and even authorized an organ transplant, since its plans went live Jan. 1. Still, Kaplan isn’t the only CO-OP member reporting issues with networks.

Nolimal said a client called last week to tell him that a local cancer center turned her away because the center was no longer in the CO-OP’s network as of Jan. 1. Nolimal said the cancer center confirmed this when he called to follow up.

Also last week, an administrator for a local allergy and asthma doctor called Nolimal to say neither he nor any other allergy specialists in town have signed contracts with the CO-OP. The doctor’s staffer told Nolimal the office has nonetheless cared for a dozen CO-OP members “just for the good of the order, to take care of people.”

Nolimal said doctors on the Culinary’s networks tell him the CO-OP gave them a verbal network commitment in early December, but as of last week those doctors had not been sent a written contract. They don’t want to “get combative” with the CO-OP, because many providers have big patient numbers through the Culinary’s contracts, he said.

The CO-OP’s Facebook page carries a number of consumer complaints, including one from a woman who said the only plan-based gynecologist near her has three malpractice allegations on his record. Another post was from a woman who described being “escorted” out of her primary-care doctor’s office for having “unbillable” coverage.

Nolimal said the problem with the CO-OP mystifies him.

“It seemingly would have been the easiest part of the transition,” he said. “You would just amend the existing (Culinary) contracts with providers to say they’re also working under the Nevada Health CO-OP.”

But asking the CO-OP what the issue is, or when it will be fixed, isn’t getting Kaplan or Nolimal answers.

“They basically didn’t know what to tell me,” Kaplan said.

Her broker told her she would have to cancel her plan, create a new account through the exchange’s website, choose a new plan, stop paying for her current plan, and deactivate her CO-OP plan when her next policy is in place.

The CO-OP did call Kaplan back Friday, after she wrote on the insurer’s Facebook page, to tell her she may be able to switch to a different CO-OP plan with her doctors in the network. But Kaplan wasn’t sure by press time what the plan would be, or whether it would cost more; it did appear that her new coverage might come with higher copays.

For Nolimal, queries to the CO-OP about its problems have gotten him this: “The verbal response is, ‘We are working on it.’”

That’s not enough for brokers because of concerns about potential liability, he said.

“I have been misrepresenting this to my clients for the last 105 days, saying that the CO-OP is being represented by the Culinary’s network,” Nolimal said. “It scares me. My signature is on documents that place business in force with them. For me and my agents trying to sell through the CO-OP, what are you doing to me as far as liability?”

The issues are also a blow for consumers who were promised coverage under the new law.

“I was way for Obamacare because finally, insurers can’t ignore a pre-existing condition,” said Kaplan, who will eventually need a knee surgery that her pre-Obamacare policy wouldn’t cover.

Now, Kaplan says she’s beyond frustrated.

“I understand that something new always has glitches. But when I pay money for something, I want someone to stand behind what I purchased,” she said. “If the people I’m talking to don’t have answers to my questions, there are plenty of people out of work these days. Fill those positions with people who know the answers.”

Contact reporter Jennifer Robison at jrobison@reviewjournal.com. Follow @J_Robison1 on Twitter.