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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

What's a Physician to Do?

By on | 5 Comments

Question: I work for a private physician's office, and we have multiple patients switching to CC. How do we know if we can still see these patients? Do we need to contract? If so, how do we do that? Also, how do we set a reimbursment rate? None of this is clear on the website. Is there even a providers line to call?

Answer: Providers do not contract with Covered California directly, but with each individual carrier selling plans through CC. So you need to contact Anthem, Blue Shield, Health Net, etc. and inquire about getting included in their 2014 Individual and Family Plan networks.


[I was about to add the following when I accidentally posted my response.]

But if you have proof that a physician is doing this, it needs to be reported to the California Dept of Insurance or Dept of Managed Health Care, depending on whether a PPO or HMO is involved (you mentioned Blue Shield, which is only offering PPOs, so that would mean complaining to the CDI not the DMHC).

I do not believe there is anything wrong with identifying the plan a person has qualified for. It cannot result in “redlining” or any other diminution of benefits or services provided to a physician.

The physician contracts to receive capitation and other “incentives” in an HMO (my physician’s complete office expenses, including his staff are paid for by the medical group he has joined in exchange for a reduction in his capitation), or higher reimbursements in a PPO. Those payments are made irrespective of the coverage.

The only difference the physician might see is in the copay a patient leaves. HMO physicians largely exist on capitation and the fact that most only see a relative handful of their office’s enrollments on a monthly or annual basis.

If a physician is found to be denying services to a patient in the manner you suggest, Eric, he or she is in grave danger of losing the license to practice medicine on which was spent hundreds of thousands of dollars to obtain. That’s not a very good trade-off.


The new health care law and plans were in the planning stages for a long time. I also have to agree it is rather astonishing that health care providers are not prepared after the roll out. Also, there will be changes coming. When you enroll in a new plan, your doctor you go to for the last 15 years suddenly disappears from the provider directory under the new plan you choose. If you receive a subsidy due to your income restrictions they print on your Blue Shield Card the lettering, “enhanced 200 subsidy” when you choose the Silver 87 PPO plan. The lettering, “enhanced 200 subsidy” should not be printed on anyone’s ID Cards. There should not be any wording on your insurance ID Cards stating you are getting a subsidy. This information can be used adversely to ‘redline’ you when you get services. Some will say, “Oh you are getting a subsidy?” Why?. A subsidy is none of anyone’s business. Just like Medicaid or Medical. Many doctors do not take Medicaid or MediCal.

I wouldn’t put the blame on the “person who works for a Physicians office” being clueless. Try talking to a Customer Service Rep at CoveredCA and you might be amazed how clueless they are.

Physicians who have never participated in HMOs or PPOs don’t know what they are supposed to do — it’s the HMOs and PPOs that usually go out looking for the providers, offering incentives to be exclusive (not participating in multiple networks).

Phil’s answer is accurate. The physician simply needs to contact the insurers and see what they have to offer, then make a decision about which company(ies) to join.

It’s truly astonishing that someone who works for a Physicians office can be so clueless about the ‘new system’. It really says a lot about healthcare in the US and how disconnected all the parts are.

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