Assessing how Well Insurers Actually Cover

To decide which companies to recommend/select, for individual health insurance, it would help to have data about how good those companies are when a consumer faces a significant health problem. Inexpensive premiums are no good if the insurer doesn't deliver.

For example, if lots of health care providers accept a particular insurance plan, then hopefully the customer would enjoy the option of sticking with a trusted doctor or choosing doctors based on reputation.

As a simple test, I searched for providers near my ZIP code, using both the Anthem and Blue Shield of California websites. For several doctor specialties I tested, Anthem's website listed significantly more doctors than Blue Shield when I selected seemingly equivalent EPO and PPO plans.

But then I played with a search tool ("Powered by Stride Health") provided at the US News & World Report website's health insurance section, and it seemed to suggest that Blue Shield would have far more providers.

So how does a consumer know what to believe?

Other aspects include quality of care and customer service. Reviews on yelp.com and elsewhere suggest that many insurance companies are simply horrible at dealing with their customers. But those reviews are presumably biased; for one thing, angry customers are more likely to think of writing a review than contented customers. Are Consumer Reports' evaluations better, because their sample is more random? Are there other surveys that are even more rigorous?

For an example of why I question Consumer Reports, consider that their magazine's Californian readers give high ratings to Kaiser Permanente. But maybe that's because those readers mostly have experience with Kaiser's primary care, which apparently has been greatly improved. What happens to the unlucky few Kaiser members who need specialists for serious health problems?

Likewise, surveys about the tendency of insurers to deny claims would be very valuable. Does this kind of info even exist?

Quality data would be great for our own personal choice of coverage, and for recommending insurance to people.

I'd love to hear all your thoughts about this. Thanks!
 
Switcheroo, because the online sources for matching doctors with plans are filled with errors and never 100% up-to-date, it's best to call a physician's office and ask if he/she accepts a specific plan..if having that doctor is an important consideration.

Also, you have to read the SOB (Summary of Benefits) carefully for each plan. I was amazed to see that most IL companies have NO LIMIT on how much $$$ an insured patient is liable for, when being treated outside of their insurance plan's network. (No Out-of-Network Stop Loss)

There's a lot of information (via news stories) regarding insurer performance at this website: The Health Law | Kaiser Health News You'll have to wade through a lot of stories to pull out the nuggets you're looking for, however.

As far as I know, there's no "Under-65 Insurer Quality Rating" for companies/plans, like there is with Medicare Advantage. But it would a logical next step for CMS to implement this, if the current high rate of complaints doesn't subside.

BTW Switcheroo, your written communication style is flawless, IMO. Maybe you're in the wrong line of work? (smile)
ac
 
You are over-thinking the situation.

Under Obamacare consumer (and agent) complaints have skyrocketed as carriers are overwhelmed with the additional administrative work created by Obamacare.

Plans change every year. What is "good" now may not be next year. Or it may not even be offered.

Networks change fluidly.

Obamacare is a moving target. Jump in when it comes by then jump off at the end of the year and grab a new one.

You are no longer buying health insurance, you are renting it for a year at a time.
 
I've been stalling my reply to you, while researching more.



Switcheroo, because the online sources for matching doctors with plans are filled with errors and never 100% up-to-date, it's best to call a physician's office and ask if he/she accepts a specific plan..if having that doctor is an important consideration.

I tried that a couple weeks ago, when I phoned the medical group where I get primary care. They told me that I must check with the insurance companies to see whether they are in-network for a given health plan. My doctor's office either doesn't know or can't be bothered to give me a complete list!



Also, you have to read the SOB (Summary of Benefits) carefully for each plan. I was amazed to see that most IL companies have NO LIMIT on how much $$$ an insured patient is liable for, when being treated outside of their insurance plan's network. (No Out-of-Network Stop Loss)

That's an awful lot of reading, especially if I will try to keep current on everything.



There's a lot of information (via news stories) regarding insurer performance at this website: The Health Law | Kaiser Health News You'll have to wade through a lot of stories to pull out the nuggets you're looking for, however.

As far as I know, there's no "Under-65 Insurer Quality Rating" for companies/plans, like there is with Medicare Advantage. But it would a logical next step for CMS to implement this, if the current high rate of complaints doesn't subside.

Thank you for the interesting leads. That led me to some interesting ratings of surgeons, at least for a few procedures. But like you said, there don't appear to be ratings for companies/plans, which is what I really need. I saw very little information (via news stories) that I could use, regarding insurer performance.



BTW Switcheroo, your written communication style is flawless, IMO. Maybe you're in the wrong line of work? (smile)
ac

Thank you for that wonderful compliment. I was careful in crafting and editing my message, because I and others have a serious need to figure all this out. And I wish I knew what the right line of work for me is.

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Obamacare is a moving target. Jump in when it comes by then jump off at the end of the year and grab a new one.

You are no longer buying health insurance, you are renting it for a year at a time.

Ok somarco, but how do we decide which plan to jump on each year?
 
I've been stalling my reply to you, while researching more.


I tried that a couple weeks ago, when I phoned the medical group where I get primary care. They told me that I must check with the insurance companies to see whether they are in-network for a given health plan. My doctor's office either doesn't know or can't be bothered to give me a complete list!

Your medical provider group is blowing you off, Switcheroo.

Since insurance companies supply most of their revenue, medical groups know exactly what insurance companies and plans they do/don't accept, how much each company/plan reimburses them for each treatment, and a host of other variables. Some medical providers have more money invested in the income generating side of their business/practice, than they do in the health and healing side.
 
Actually they don't AC.


Carriers consider their reimbursement schedule to be confidential. They don't share it with anyone.
 
Actually they don't AC.


Carriers consider their reimbursement schedule to be confidential. They don't share it with anyone.

You're saying that Medical providers don't know in advance how much they will be reimbursed for each procedure?
 
You're saying that Medical providers don't know in advance how much they will be reimbursed for each procedure?

Yes, I am.

They have an idea, probably a better idea of what Medicare will pay but not so for U65 health insurance or MA plans.

When you consider a carrier like BX may offer 100 different plans (group, IFP, HMO, PPO, POS), all with different underlying plan designs, they really don't know how much they will be paid until the money arrives.

Fees are trade secrets. The MCO agreement provides a guideline relative value but does not break it down by ICD-9 (or 10) codes.

A medical practice that deals with multiple carriers would have to know the codes and which contract was used for each patient. That operation is farmed out to billing firms that collect raw data from the practice, verify the codes then batch file with the carriers on a daily basis.

And no, the billing firms don't know how much to expect in reimbursement, nor do they care.
 
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