Health Insurer Centene Is Sued Over Lack of Medical Coverage

Posted January 11, 2018 3:41 p.m. EST

People who bought policies from Centene, a large for-profit health insurance company, filed a federal lawsuit Thursday claiming that the company does not provide adequate access to doctors in 15 states.

“Members have difficulty finding — and in many cases cannot find — medical providers,” who will accept patients covered under policies sold by Centene, according to the lawsuit filed in federal court in Washington state.

“Centene misrepresents the number, location and existence of purported providers by listing physicians, medical groups and other providers — some of whom have specifically asked to be removed — as participants in their networks and by listing nurses and other non-physicians as primary care providers,” the lawsuit claims.

People signed up for insurance and “they suddenly discovered there were no doctors,” said Seth Lesser, a partner at the law firm of Klafter Olsen & Lesser who is representing some of the policyholders.

A spokeswoman for Centene said the company had not seen the lawsuit. “We believe our networks are adequate and we work in partnership with our states to ensure our networks are adequate and our members have access to high-quality health care,” she said in an email.

Centene, which also provides coverage to low-income individuals under the government Medicaid program, has proved to be one of the mainstays of the Affordable Care Act. After many other large insurers abandoned the individual market created by the federal law and as President Donald Trump has sought to dismantle the law, Centene doubled down and has become one of the largest insurers still offering policies.

But the lawsuit underscores a critical question about whether Centene offers plans that provide its customers with access to the level of care required under the law. The suit claims that many doctors won’t accept patients covered by Centene because of the company’s refusal to pay legitimate claims.

As insurers like Centene have relied on smaller networks to control costs and better manage the care of patients, consumer advocates and others have raised concerns about whether some plans offered under the law provide sufficient access to doctors and hospitals. The law requires plans to meet certain minimum requirements.

The lawsuit recounts numerous examples of patients unable to find in-network doctors. In Washington state, Cynthia Harvey was billed for hundreds of dollars in medical costs after she discovered some of her care was out of network. When Harvey went to the emergency room last year, she was billed $1,544 by the doctor, and the lawsuit claims Centene had no emergency physicians participating in its network in the Spokane area at the time.

The insurer also denied some of the claims from a colonoscopy she had because she was at high risk for cancer, according to the lawsuit. Harvey successfully appealed many of the denials to state regulators, the lawsuit said.

The lawsuit comes on the heels of a decision last month by Washington state regulators to fine Centene up to $1.5 million for having an insufficient network of doctors to treat people who signed up for plans sold under the Affordable Care Act. State officials said they received more than 140 complaints from people who had trouble finding a doctor, particularly a specialist like an anesthesiologist, who accepted the insurance or from individuals who received a surprise bill after they received treatment.

In a statement about the consent order the company reached with the state to be allowed to continue selling policies for 2018, Centene said that it was committed to addressing “known issues in our network in select regions of the state” and that it had taken actions to make sure its customers had access to services.

The company announced this week that it now covers more than 1.4 million people through the state marketplaces, with its chief executive, Michael F. Neidorff, describing its growth in the market as “so dramatic.” Centene attributes some of its success to its experience providing care under the Medicaid program or in its low-cost networks.

Steven A. Milman, a periodontist in Round Rock, Texas, who is one of the plaintiffs in the lawsuit, signed up for an Affordable Care Act plan from Centene last year. He and his wife, both 59, paid about $1,200 a month for coverage. Milman had a previous policy from UnitedHealth Group. “They had a good panel of doctors and easy access,” Milman said in a telephone interview. But UnitedHealth lost money in the market and stopped selling policies, so he and his wife were forced to find another insurer.

Choosing between the local Blue Cross plan and one offered by Centene, Milman picked Centene after seeing that its network included a large medical group in Austin and getting recommendations for several doctors at that group. “I bought Centene on that promise,” he said.

But Milman soon learned that finding a doctor within the network was much harder than he anticipated. The medical group he had picked was no longer in the network. When he called the doctor’s office assigned to him by Centene, it turned out to be a obstetrician/gynecologist. “We don’t see men,” he was told.

Milman’s wife had no better luck. When she came down with an earache, she was on the phone with the plan for five hours before being sent to a clinic where she was treated by a nurse with no doctor on site.

By the summer, Milman was fed up. He continued to see the doctor he had under the UnitedHealth plan, paying out of pocket for the visits. But he said he worried about what would happen if he were hospitalized and felt like he didn’t really have insurance. He switched last summer to a Blue Cross plan that he could get because he was self-employed. “Blue Cross is a good plan with a good panel of doctors,” he said.