Passing the Buck: Letter to Complaint Examiner (Updated Aug 25)

Spring time lapse copy
Ohio passed the buck to the Feds again, this time in regard to provider network problems.

August 6, 2016

Dear Barbara Smith Bain, Complaint Examiner Supervisor at the Ohio Department of Insurance,

There are several mistakes in your August 3 closing letter to me concerning my complaint about Medical Mutual’s inaccurate provider network directory and unwarranted high price.

First of all, the provider network issue. Because you have given Medical Mutual a pass to have grossly inaccurate provider network lists — did you even bother to check? — just last week I have identified an additional 112 provider network listings that are inaccurate. 140 out of 198 primary care physicians that I called on the Medical Mutual July 2016 SuperMed PPO network that Medical Mutual has listed online as accepting new patients, are not really accepting new patients, because I called them in July and they said they were not accepting new patients. My complaint identified 28 out of 47 that I called in November that are listed this way. What a huge percentage. Were you concerned? NO. Did you even bother to check? NO! Did Medical Mutual make any changes because I brought it to their attention? NO!

Your excuse for not dealing with this problem is not acceptable.

We have analyzed the facts as presented by both you and the company. We reviewed the documentation received and the Ohio regulations .found that this policy was purchased through the ACA Marketplace Exchange, and that the Exchange is under federal jurisdiction. At the time of the occurrence there are no Ohio Revised Code that specifies requirements for provider list information and maintenance.

Because you didn’t even bother to check in April, on what I reported on in November, that was then what I found to be a 59% inaccuracy, many more patients are NOW being hurt by the lies, deception, fraud, inaccuracies, and greed of Medical Mutual’s practice of incorrectly listing the panel status of their primary care physicians. The percentage of inaccuracies in my July survey of 198 doctors is now at 70%. Don’t take my word for it, do your own survey. Take that information behind the secrecy of your new closed door law and see what you can do about it.  I won’t be holding my breath.

Secondly, you did not address the outrageous 224% increase of my plan when it went on the Marketplace in 2014. It had all the ACA compliances in it already, in 2011. Why did it go up 224% the year it went on the Marketplace?  Please send me the actuarial memorandum and initial rate filing for the Medical Mutual 2014 Exchange plans, so I can see for myself how this increase was justified.

Thank you,

Penny Gentieu

Doctors listed as accepting new patients, but when I called them, they told me that they are not accepting new patients.

Doctors crossed out are some of the doctors listed as accepting new patients in July 2016, but when I called them, they told me that they are not accepting new patients. They were also listed as accepting new patients in November 2015, but when I called them in November 2015, they were not accepting new patients.

UPDATE ON AUGUST 23   I received this reply by email:
August 23, 2016

Re: Consumer Services Division File Number: CSD-0034217

Dear Ms. Gentieu:

Thank you for contacting the Ohio Department of Insurance (ODI) with your complaint regarding your provider network issue with Medical Mutual of Ohio (MMO). This letter is a follow up to your email received on August 6, 2016.

We understand from your email that you are not satisfied with the response you received from the Department regarding your complaint. You also provided the Department with information on network accuracy for July 2016 developed from your on line directory research.

We again reviewed the information provided by both parties and the applicable Ohio insurance regulations for the 2015 and 2016 periods. Under current regulations the network directory is required to be updated at least quarterly. The directory information is self-reported by the provider to the insurer.

When updates are received the insurer updates the directory, however it is the providers’ responsibility to provide accurate information, such as if they are accepting new patients.

Please understand that the jurisdiction of the Ohio Department of Insurance is to provide consumer protection through education and fair but vigilant regulation of Ohio insurance laws. In this case we have applied the Ohio insurance regulations to the information parties have provided and found no evidence that the company has acted improperly.

In regards to the 224% rate increase which you feel was not addressed. You stated in your November 30, 2015 letter to us that the rate change was for a similar plan sold on for 2014 compared to the cost of the plan you had in 2013. It appears your earlier plan was a separate pre-Marketplace individual plan. Also, it appears that MMO addressed your concern in their January 21, 2016 response letter regarding the difference in the premium rates from one year to the next in light of pre and post ACA requirements.

Your public records request to the Department for Medical Mutual’s 2014 actuarial information and initial rate filings for exchange plans has been forwarded for review and fulfillment. Please understand that some records may not be available due to state retention schedules. 


Barbara Smith Bain, Supervisor
Complaint Processing Unit
Consumer Services Division
Phone: (800) 686-1526 ext. 43393
Fax: (614) 719-1608
Down the memory hole it goes….

It’s so interesting — this one-page press release the Ohio Department of Insurance issued on August 24, below. They report that the average premium only went up 91% in the individual market from 2013 to 2017. Yet my really thorough, individual market Medical Mutual insurance went up 277% from 2013 to 2016, for basically the same insurance.  Gee wiz, and now they might not even ever let me know what the actuarial reason is from the initial rate filings, because they plan on burning the information just as quickly as they possibly can.

Ohio Department of Insurance August 24, 2016 press release:

Screen shot 2016-08-28 at 4.17.08 PM

(there it is, the very last link)

Screen Shot 2016-08-25 at 8.13.43 PM

(click here to see original linked press release)


I couldn’t find the NAIC Supplemental Health Care Exhibit for 2013, but  I did find it for 2014, and the weighted average annual premium per covered life for comprehensive health insurance in the Individual Market is $3,446 for 2014, which would make it a mere 30% increase from 2013, and we know that’s not true, from ODI’s own 2013 reports, so what’s up with this comparison that doesn’t sync with these facts?

Wish we could see the 2017 Rate Templates, which are not made public. What do they mean about not incorporating Trend into the calculation — Trend is part of every issuer’s actuarial memorandums that support their rate hikes, and that’s where they get the member months, so what is the Rate Data Template figure, if not the asked for, and undoubtably granted rate increase that the rate justifications are based on? And what is with this spartan one-page report? Is that ALL they have to say? Apparently the ODI issued this puny little report to comply with their idea of effective rate review!


2 thoughts on “Passing the Buck: Letter to Complaint Examiner (Updated Aug 25)

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