2016 Provider Network Survey


This survey was made in July and August 2016 of all the internal medicine and family practice primary care doctors listed on the networks of healthcare.gov plans offered by Anthem, Paramount, Med Mutual-Promedica, CareSource, Molina, and Buckeye Ambetter within 15 miles of 43615, Toledo, Lucas County, Ohio. On each provider network directory connected to the plans on healthcare.gov, I searched for internal medicine and family practice primary care doctors who are accepting new patients. I compiled a list of all the doctors listed as accepting new patients, totaling 308.* I called their offices and asked if they were accepting new patients.

Ohio Citizen Rate Review Provider Network Survey


To Recap:

  • Anthem Blue Cross Blue Shield has 13, not 39 PCP family practice and internal medicine doctors accepting new patients. 67% inaccurate.
  • Paramount has 31, not 89 PCP family practice and internal medicine doctors accepting new patients. 65% inaccurate.
  • Med-Mutual-ProMedica has 20, not 136 PCP family practice and internal medicine doctors accepting new patients. 85% inaccurate.
  • CareSource has 17, not 166 PCP family practice and internal medicine doctors accepting new patients. 90% inaccurate.
  • Molina has 36, not 159 PCP family practice and internal medicine doctors accepting new patients.  77% inaccurate.
  • Buckeye Ambetter has 10, not 98 PCP family practice and internal medicine doctors accepting new patients. 90% inaccurate.

The average of the  six percentages representing the inaccuracies, misrepresentations, falsely advertised lies, untruthfulness and phoniness in our Toledo provider network databases is EIGHTY PERCENT !!

 Here are some things I was told by the doctors offices:

Seven said they keep calling to have the list changed but they don’t update, one moved to Arizona, one moved to California, one moved to Oak Harbor, one moved to Bowling Green three years ago, two are retired, one isn’t practicing anymore, six you must pay an additional annual membership fee of $1,650 and they still take your insurance,  five are geriatrics only, two more only see patients in the nursing home, one more only sees patients in Hospice, two only see mental health patients, five said they have no control over the lists, one only sees Owens Corning employees and asked twice to be taken off the list, eight screen for age, address, state of health and doctors you’ve seen and then decide if they are accepting new patients or not, 15 do not accept new patients but their residents do, 26 do not accept new patients but their nurse practitioners do, one is not practicing medicine anymore, two are not PCPs, one only sees addiction program patients, eight are hospitalists, one is a hematologist, one is a sleep doctor, five are kidney doctors, not PCPs, one sees only adolescents, one is a pediatrician, three are sports doctors, six were not locatable, more than one said they put doctors on the list without asking and they never update them, one said they haven’t accepted new patients for 30 years, etc., etc., etc….

Ironically, Lucas County has one of the highest resident to PCP ratios in the entire state of Ohio, so why is it that the overwhelming majority of PCP doctors are not taking new patients? Are they being extinguished by insurance companies by not being paid enough money, useful in name only for the time being, to populate provider network directories that lead to nowhere in an Orwellian scheme that controls utilization and increases corporate wealth, or what?


*I called all 78 internal medicine doctors and all 204 family practice doctors. I also called 26 doctors on the lists who were actually not PCP’s, but doctors of other specialties who came up in my search for internal medicine and family practice PCP’s, who were wrongly listed, such as hospitalists, cardiologists, nephrologists, psychiatrists, pediatricians, pulmonologists, sports doctors, critical care doctors, gerontologists, and an occupational medicine doctor.

The Skinny on Narrow Networks in Health Insurance Marketplace Plans is a study made by the Robert Wood Foundation. It quantifies what makes a small or extra small network. Toledo has maybe 450 primary care physicians. An extra-small network has 11% or less of the total number of physicians practicing in an area. That would be about 50 PCPs in Toledo. A small network has 30% or less, which for Toledo would be about 135 PCPs. The insurers are lying about the doctors’ availability to make their networks seem larger. Doctors that don’t accept new patients and haven’t for years can hardly be considered in-network for new patients. From my survey, which shows 13 to 36 PCPs available in the network to new patients, not even one of those is of a sufficient sized network to be allowed to sell on the Marketplace.



For example, my CareSource complaint to the Ohio Department of Insurance:Screen Shot 2016-08-16 at 2.47.41 PM

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Excerpt from CMS’s 2017 letter to Issuers:

What will the CMS do about Toledo’s grossly inaccurate provider databases?

v. Network Transparency 
This section discusses how CMS intends to label each QHP network’s breadth as compared to other QHP networks on HealthCare.gov. This information will be available to consumers when they are considering which plan to enroll in, and would include a designation that indicates the network’s relative breadth. We intend to further consider how we will display this breadth information as we continue consumer testing. The purpose of the labeling is to provide increased transparency to enrollees about the type of provider network in the coverage they are selecting.

Each network’s breadth will be compared to the network breadth of other QHPs available in the same geographic area. CMS will identify network breadth based on analysis of QHP provider and facility data submitted as part of the 2017 certification process. This analysis will compare an issuer’s contracted providers to the number of specific providers and facilities included across all QHP networks available in a county. The rating will focus on hospitals, adult primary care, and pediatric primary care with either a separate classification for each of the three categories or a composite overall classification that reflects the overall network for all three of the indicated specialties. CMS will make a final determination to use a separate or composite rating based on the results of consumer testing, and intends to provide this information as part of the 2017 QHP certification instructions. These specialty areas were chosen based on consumer feedback that access to specific hospitals and preferred primary care physicians is important to potential enrollees when comparing plans.

We plan to provide the classifications of network breadth for each plan at the county level. These classifications will be determined by calculating the percentage of providers in a plan’s network, compared to the total number of providers in QHP networks available in a county. We will divide the number of each QHP’s servicing providers at the issuer, network, county, and specialty combination level by the total number of all available QHP servicing providers for that county, including Essential Community Providers (ECPs). This number is the Provider Participation Rate (PPR). As a baseline standard, networks that are within one standard deviation of the mean PPR will be classified as Standard. Those with a PPR that is more than one standard deviation above the mean PPR will be classified as Broad. Those with a PPR that is more than one standard deviation below the mean PPR will be classified as Basic. Applying this methodology to 2016 QHP issuer provider data, we found that approximately 68 percent of the plans would have been categorized as Standard, about 16 percent would have been classified as Basic, and about 16 percent would have been classified as Broad. We will conduct an analysis of QHP 2017 provider data using the same methodology to determine each plan’s classification. These calculations will be based on the network provider data that each QHP issuer submits as part of QHP certification and would be updated annually.

A form on Network Adequacy new this year that is filled out with the insurer’s rate filings (are these public records available on SERFF?):

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The lack of transparency in Ohio is appalling. Instead of having effective rate review, we are kept in the dark, the perfect breeding ground for corruption. See this blog post regarding the final outcome of my Medical Mutual provider network and pricing complaint, including the part at the end where Ohio issues an August 24 report on rate hikes from 2013 to 2017: http://ohiocitizenratereview.info/letter-complaint-examiner/

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Related: Letters to Insurers

Related: Provider Network Complaints Get Buried

Related: Medical Mutual SuperMed PPO Provider Network