Chad Terhune, Kaiser Health News
Ashley Summers mentioned she acquired an disagreeable shock in February when she tried to select up a prescription for her rheumatoid arthritis: Her pharmacy mentioned her insurance coverage had been canceled, despite the fact that her premiums have been paid.
Summers referred to as Blue Shield of California and acquired her coverage reinstated — then she mentioned it occurred once more in March and this time, the lapse in protection dragged on for 3 months.
Without insurance coverage to cowl her medicines and physician visits, her arthritis and fibromyalgia worsened to the purpose that she might barely stroll, she mentioned. In June, she mentioned, the state granted her permission to modify to a different insurer.
“This entire mess has been so incredibly stressful,” mentioned Summers, 49, a private assistant in Los Angeles who had paid $593 a month in premiums. “For Blue Shield just to pull the plug like this is infuriating.”
Around the state, customers with particular person Blue Shield insurance policies, like Summers, say they’ve been topic to sudden, faulty cancellations, particularly in latest months, forcing them to go with out coronary heart drugs, skip vaccinations for his or her kids and pay a whole lot of dollars out-of-pocket for different medical care. On social media, prospects have described frantic makes an attempt to get their protection reinstated.
We apologize for the inconvenience. DM you member ID and a Specialist can look into this for you. – AV https://t.co/XQLGzcD88Q
— Team Shield (@TeamShieldBSC) July 2, 2018
We apologize for the difficulty and want to look into this. DM us your member ID and speak to information and a member of our workforce will attain out to handle this with you. – JN
— Team Shield (@TeamShieldBSC) July 31, 2018
We apologize for the frustration. A Specialist will attain out shortly to help you. – JN
— Team Shield (@TeamShieldBSC) July 30, 2018
Blue Shield has acknowledged failures in enrollment and billing for some prospects who bought particular person insurance policies since 2014, each inside and out of doors the Covered California change. The firm declined to specify what number of prospects have been affected. The issues don’t seem to contain folks with employer protection or enrolled in authorities well being packages.
In a June 22 lawsuit, the San Francisco insurer blamed many of those issues on an out of doors contractor it had employed in preparation for the launch of the Affordable Care Act in 2014. In a countersuit, the contractor, HealthPlan Services, denied the allegations and accused Blue Shield of sharing inaccurate buyer knowledge.
In a statement, Blue Shield mentioned: “The roll out of the Affordable Care Act was hard on the entire health care system. Our vendor failed to provide the support it promised and we spent millions of dollars to mitigate the impacts to our members.”
On Friday, Summers sued Blue Shield in Los Angeles County Superior Court, alleging breach of contract and in search of class-action standing on behalf of different prospects. The insurer couldn’t be reached for remark concerning the grievance.
Scott Glovsky, a Pasadena, Calif., legal professional representing Summers, mentioned Blue Shield has recognized about these issues for years. “Blue Shield is taking people’s hard-earned dollars and then abandoning them when they’re sick,” he mentioned.
Tina Hoover, 47, a horse coach in Sherman Oaks, Calif., mentioned Blue Shield canceled her coverage twice in two months, despite the fact that she’d been paying her premiums faithfully for years.
Blue Shield denied greater than $1,000 in physician visits, saying she’d been terminated. After 4 calls, inconsistent responses, non-responses and a pointed remark by her husband on Twitter, she lastly acquired her insurance coverage again, she mentioned.
“It was frightening that Blue Shield could be so disorganized on something so important like my health care,” mentioned Hoover, who pays $858 a month in premiums and has been a policyholder with the insurer for 15 years.
All well being insurers face complaints, from improper denials of care to annoying customer support. But some consultants say these persistent breakdowns in customer support at Blue Shield characterize a black eye for California’s third-largest well being insurer, which has 460,000 prospects on the Covered California change and three.eight million enrollees general.
“I’ve never seen anything on this scale for such basic insurance operations,” mentioned Paula Wade, an business analyst at Decision Resources Group in Nashville, Tenn. “Honest to goodness, if you can’t take people’s money and credit their account — that’s incredibly simple.”
We apologize for the frustration. DM us your member ID and a member of our workforce will look into this. – SS https://t.co/XQLGzcD88Q
— Team Shield (@TeamShieldBSC) July 25, 2018
We’re sorry for the inconvenience. DM us your member ID and a Specialist will look in to this for you. – AV https://t.co/XQLGzcD88Q
— Team Shield (@TeamShieldBSC) July 2, 2018
I hardly ever tweet, however @BlueShieldCA has absolutely the worst customer support. They by chance terminated my insurance coverage, and apologized for the error. After dropping approx. 13 hours of labor time on the telephone, nonetheless no answer. What the heck??
— Paris Hotel Boutique (@parishotel) January 3, 2018
Across its plans final yr, Blue Shield had the highest complaint rate per 10,000 enrollees among the many eight largest well being insurers statewide, in line with the California Department of Managed Health Care. Blue Shield had 7.43 complaints per 10,000 enrollees, adopted by Anthem Blue Cross (5.83), UnitedHealthcare (four.72) and Kaiser Permanente (four.6). (Kaiser Health News, which produces California Healthline, shouldn’t be affiliated with Kaiser Permanente.)
For its particular person market plans, Blue Shield selected to outsource sign-ups, billing and fee processing to HealthPlan Services, a significant contractor for insurers industrywide. In its breach-of-contract lawsuit towards the contractor, Blue Shield mentioned it wanted outdoors assist to deal with the dramatic overhaul of the person market in 2014 beneath the ACA.
By June 2014, Blue Shield mentioned it had shaped a workforce of individuals “whose sole job was to address the failures in HPS’ services to ensure that Blue Shield’s customers’ interests were not impacted,” in line with the lawsuit.
But the glitches endured, and Blue Shield mentioned in its lawsuit that it has misplaced tens of hundreds of thousands of dollars because of the contractor’s “egregious” failures on billing, refunds and associated issues.
HealthPlan Services’ “data was ever-changing, inconsistent and flat-out incorrect,” Blue Shield mentioned within the 15-page grievance in San Francisco federal court docket.
In a press release to California Healthline, HealthPlan Services referred to as Blue Shield’s claims “baseless” and mentioned it has a “successful track record of providing quality services to its clients and their members.”
But in court docket papers, Blue Shield mentioned the issues went past the sudden cancellations.
For occasion, about 14,000 Blue Shield prospects skilled “multiple attempted charges on their bank accounts” over one weekend, in line with the insurance coverage firm’s lawsuit. About half the time, Blue Shield alleged, its contractor proposed refunds or credit that have been extreme or had no foundation in any respect. One time, a $27,000 refund went to the fallacious buyer, in line with the lawsuit.
In April 2017, Blue Shield mentioned, it initiated termination of the seller’s contract.
In an Aug. 13 counterclaim, HealthPlan Services mentioned “Blue Shield’s highly unusual data maintenance and transmission methods and business processes resulted in customer-facing errors that were directly attributable to Blue Shield’s conduct.”
In a press release, Blue Shield countered that “HPS’ allegations are unfounded and we look forward to responding to them in the legal proceedings.”
Meantime, San Francisco resident Burcu Sivrikaya, 32, mentioned she discovered late final month that Blue Shield had canceled her protection — efficient May 1. She spent hours on the telephone speaking to seven totally different firm representatives attempting to get her coverage reinstated, solely to be advised it will take 30 days, she mentioned. “Are they using pen and paper? Why does it take 30 days? It’s insane.”
Now Sivrikaya, a social media supervisor, is attempting to get Blue Shield to refund the $1,179 she mentioned she paid in premiums for the three months the corporate withdrew protection.
The Department of Managed Health Care fined Blue Shield and a subsidiary $557,500 final yr for improper cancellations and quite a lot of customer grievance violations. Blue Shield is contesting a few of these allegations and penalties, in line with the state.
Blue Shield famous that it carried out effectively on sure classes within the state knowledge, corresponding to a particularly low grievance fee amongst medical suppliers.
The firm additionally mentioned its buyer satisfaction rating improved in a latest client survey by Forrester Research, growing by almost 2 share factors to 63.6 out of 100. Forrester nonetheless labeled Blue Shield’s efficiency as “poor,” placing it in ninth place out of 17 well being insurers that have been rated this yr.
This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.
Kaiser Health News (KHN) is a nationwide well being coverage information service. It is an editorially impartial program of the Henry J. Kaiser Family Foundation which isn’t affiliated with Kaiser Permanente.
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