Lawsuit filed by patients against narrow network of major PPO – isolated or bellwether?

Something’s gotta give…….. and apparently it is.

Patients want to receive quality care from familiar providers on a timely basis at lower costs.

Doctors and hospitals want to maintain and increase current levels of reimbursement.

Insurance companies needing to comply with the new ACA requirements and control costs are squeezing provider reimbursement rates and eliminating those providers that won’t accept lower rates.

With all this going on employers and their employees are more concerned than ever about cost, coverage, and access to doctors and hospitals. Some feel cornered and are starting to take action.

A lawsuit was recently filed by some new customers of a major California PPO. The outcome of the suit, and others like it that are to follow, could signal how things will take shape down the road in terms of reliable and continued access to a given doctor or hospital at any point in time.

According to the suit filed against Blue Shield of California, the customers did their homework before signing on with one of Blue Shield’s narrow network products. Before purchasing their plans they checked the insurance carrier’s website directory and called the insurance carrier, the respective treating providers, and the providers from whom they would be seeking treatment to confirm participation in the specific network. Later they came to find out that those providers were either dropped from the network without notice or were never considered in the network at all.

In layman’s terms the lawsuit appears to center on a combination of misrepresentation, false advertising, and lack of good faith effort to communicate changes as it pertains to provider network composition and how services will be covered.

We’ll report back on anything significant as this story plays.  In the meantime look for a series of posts from us highlighting pragmatic and creative approaches taken by some engaged employers to maintain employee and dependent access to key providers without increasing costs. If you have something you’d like us to address or have your own story to share please drop us a line.

You can read more about the California lawsuit in When a PPO isn’t.”



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