SAN FRANCISCO (KPIX 5) — For months, KPIX 5 ConsumerWatch has been reporting that many newly-insured consumers on Covered California haven’t been able to find a doctor under their new plans. Now, even insurers are telling some they are out of luck.
In the meantime, state regulators haven’t issued a single fine for too few doctors or inaccurate lists.READ MORE: San Francisco Serial Shoplifting Suspect Charged With 15 Counts, Faces Arraignment Wednesday
More On Covered California Issues:
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- Some Doctors Surprised To Be On Covered California Provider List
- Covered California Removes Doctor Lists After KPIX 5 Report Finds Mistakes
- Some Doctors Listed By Covered California Not Taking Coverage
Kyle, a former Marine who lives in the Bay Area, has been trying to manage his condition of chronic Lyme disease that contracted while on active duty. He juggles a number of medications as well as weekly IV treatments.
But the tougher, more exhausting task is trying to find a doctor who will accept his Anthem Covered California insurance.
“I was on the phone with Anthem for two hours while they were trying to find me a doctor within 20 miles. Finally a supervisor came on the phone and said ‘Sir, we have to go, we have other people to help,’ and advised me I need to cancel my plan,” said Kyle.
Under California state law, insurers must have enough doctors to enable patients can get an appointment within 15 days and 15 miles of their home.
It’s something Kyle said he couldn’t do. He said even Anthem couldn’t find a doctor on its list to accept his policy.
Earlier this year, state regulators said they were reviewing the covered California plans for “network adequacy” to see if there were enough doctors to meet the need.
The state regulatory agency did admit earlier that while it wasn’t “exactly” checking the insurers lists for “accuracy”, inaccurately listed doctors would be a violation of state law.
KPIX 5 asked the DMHC if insurers would be held accountable if the lists were inaccurate, an official with the agency said it would look into the matter.
Yet, three months later the state still cannot tell how many, if any doctors were inaccurately listed on Anthem’s network adequacy filing.
The Department of Managed Health Care declined a recent request for a follow up interview.READ MORE: Santa Clara County Approves $750,000-Expansion For Domestic Abuse Program
But Kyle checked the list and said, “I’ll log onto my computer and show you over 80 [doctors] within 20 miles.”
KPIX 5 found many more inaccuracies than that.
And internal DMHC emails reveal, one day after we first questioned the agency about a lack of doctors, several people on the inside began echoing our concern.
KPIX 5 also learned that members of its advisory board sent emails warning the director of the agency. And the head of the department’s complaint unit warned, “I suspect we are going to have a network adequacy issue very soon.”
But while DHMC is the agency that regulates insurers, it is Covered California that determines which insurers participate in the state program.
Records show the state agency has fined Anthem over $100,000 since February for various violations, but none for lack of doctors or network adequacy.
KPIX asked Covered California representative Dana Howard what the state will do to prevent this same situation from happening when the next open enrollment begins in October.
“We are already engaged in some very meaningful dialog with the insurance plans,” said Howard.
Howard would not confirm reports that thousands of people have switched insurers due lack of doctors.
“We have seen some cases, we don’t have a count,” said Howard, who added that his office could not disclose how many people are switching because they can’t find a doctor.
He said that would hinder their ability to negotiate with insurers.MORE NEWS: Man Involved In 2020 San Francisco Police Standoff Shot Dead in City's Bayview District
Anthem Blue Cross said that the notes in their customer service system doesn’t reflect Kyle’s story. The insurer would not elaborate or provide additional information. Anthem said it continues to expand its network.