Many LI doctors confused by NY health exchange plans

Dr. Marc Sicklick at his office in Cedarhurst Dr. Marc Sicklick at his office in Cedarhurst on Monday, Feb. 10, 2014. Photo Credit: Newsday / Alejandra Villa

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Many Long Island doctors say they are being listed on New York's health exchange plans without their knowledge, generating confusion and frustration among the physicians.

Some doctors said they are surprised to find out they are apparently listed with a plan. Others said they are shocked to learn they don't belong to a particular plan. Many say they have no idea what the reimbursement rates are, and all complain they are getting few answers.

"I'm getting patients with insurance I've never heard from before," said Dr. Deborah Dienstag, a pediatrician in Lawrence. "I tell people I don't know if this is real . . . [insurance] or not covered."

Dr. Sam Unterricht, president of the Medical Society of the State of New York, said in many cases the only way for doctors to find out if they are part of an insurer's network is to go to the website to see if they are listed.

"Most of them [websites] are horrendously bad, and it's quite difficult to know if you're in a plan or not," said Unterricht, who lives in Hewlett and is an ophthalmologist in Brooklyn.

Ordinarily, Unterricht said, doctors sign a contract with an insurance company and are given a fee schedule.

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"With the exchange plans, they just put you on the plan automatically," he said. Unterricht said he believes he is listed with six exchange plans. "I didn't actively sign up," he said. "I was just put on the plans -- and it took us an hour to figure it out."

The reimbursement rates also are hard to decipher, he said.

"In some cases the figures are available but in others they are very hard to get," he said. "You have to contact the company and request a fee schedule. It's just torture. They just don't make it easy."

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Leslie Moran, senior vice president of the New York Health Plan Association, the trade group for health insurers in the state, said some doctors might be unaware that they had signed contracts that required them to take all of an insurance company's plans.

Or they had received mailings that somehow got overlooked.

Ann Marie Gothard, spokeswoman for EmblemHealth, for instance, said that doctors were asked to participate in a new network, called the Select Care network, during the summer of 2013.

"Since that time, Select Care providers have received invitations to attend online and in-person workshops about the network, a welcome kit with the details of how to service members in Select Care plans, and notices reminding them that they were in the network for our Select Care products," she said.

But a recent medical society survey of neurosurgeons in Suffolk bears out doctors' confusion. Of the 25 neurosurgeons in Suffolk listed as participants among the eight exchange plans offered, four were no longer practicing in the county, said Regina McNally, a vice president in the society. Another 18 had "various issues," she said, ranging from not knowing which plans they were in, to not knowing what reimbursement rates they were getting, to having the incorrect address or phone number for their practice listed. Only three were fully satisfied, she said.

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"I'm very frustrated by the whole situation," said Dr. Marc Sicklick, an allergist and immunologist in Cedarhurst.

Sicklick said he got a letter informing him he is part of Health Republic's and Oscar's networks, but he is unclear what other exchange networks he might be in. He said he is asking people to sign waivers making them responsible for payments if he doesn't get reimbursed -- a practice, he said, "I don't like."

Dienstag said she is telling patients that, if she doesn't get paid within 60 to 90 days, she will bill them directly. She said despite spending hours on the phone with insurers, "I am getting little information."

Her plan? "To see what [reimbursement] comes through and sit and wait for 60 days and hope it gets straightened out in the wash," she said. "I have never seen this kind of chaos in health care."

Unterricht maintains there "should be an easy way for doctors to find out which plan they are in. We have asked the [state] Department of Health to set this up and this is one thing they haven't done yet."

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The health department said it has "encouraged the plans to take steps to ensure that providers are aware of their participation status."

And insurers said they have indeed reached out to doctors.

Sally Kweskin, spokeswoman for Empire BlueCross BlueShield, which has the largest percentage of enrollees on the exchange -- 21 percent -- said Empire notified doctors of their "inclusion or exclusion in our exchange network by mail."

Maria Gordon Shydlo, spokeswoman for UnitedHealthcare, which includes Oxford, said that the company has been "communicating with its New York physicians since last April about their participation in the marketplace."

Company spokesman Nick Rosen-Wachs said Oscar, a new insurance company, sent a postcard initially notifying providers, followed by a more detailed letter from Magna-Care, the insurance company from which it leases its network. "As a new plan, we have also taken a proactive approach in reaching out to specific providers to educate them about Oscar," Rosen-Wachs said.

A spokeswoman from Health Republic, which also leases MagnaCare's network, said it, too, had been working with MagnaCare "to make sure its providers are educated about the company and the plans they offer."

As for excluding some doctors from a plan -- so-called "skinny networks" -- Moran said they reflect a "delicate balance" that insurers must strike in providing good care at a good price.

Kweskin acknowledged that "Empire's exchange network is smaller and more heavily focused on primary care physicians than other Empire networks."

She said that WellPoint, Empire's parent company, put 55,000 consumers nationwide through "full exchange simulations" to find out what was most important to them.

"What we learned was that people are willing to make trade-offs in order to have access to affordable health care," she said. "Simulation results showed consumers were more concerned with premium savings than access to providers."

But potentially less access is upsetting to Dr. Alfred Cossari, a pediatric ophthalmologist in Port Jefferson. Cossari -- who said he really doesn't have a clue what other exchange plans he's in -- said he has enjoyed a good relationship with Empire in the past and was surprised to find that he was not part of Empire's exchange plan network.

But after some discussion, he said he learned last week that he was being included on the company's network plan.

"This pleases me tremendously because it means I can at least take care of patients that come to me," he said.

Top insurers on NY STATE OF HEALTH

18% Empire Blue Cross Blue Shield

16% Health Republic Insurance

14% Fidelis Care

12% EmblemHealth

11% MetroPlus Health Plan

Source: New York State Department of Health

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