PPOs get poor marks for claims payment, customer service

Major insurers in California do a poor job of paying claims and providing good customer service for members in preferred provider organization plans (PPOs), according to a new state survey by the California Department of Insurance.

Anthem Blue Cross Blue Shield of California, Health Net, UnitedHealthcare and Cigna received the lowest possible ratings for customer service. Aetna earned a slightly better rating of fair, the Los Angeles Times reports.

Consumers complained about the difficulty of getting someone on the phone, obtaining cost information and getting claims paid, according to the Sacramento Bee.

California Insurance Commissioner Steve Poizner told the Los Angeles Times that the findings are "atrocious," saying insurers "must step up and improve the quality" of their healthcare services in a marketplace that generates $17 billion a year in revenue. "Consumers now have much more information to make choices that are best for them, and to pressure insurers to do better. We all need to use this data to make that happen," he said in a statement.

The survey also evaluated whether PPO members received adequate medical care through cancer screenings, cholesterol testing and other services. It found that Anthem Blue Cross Blue Shield and Health Net did a fair job of meeting quality standards spelled out by national experts. Aetna, Cigna and UnitedHealthcare did a good job of meeting those criteria, according to the Times.

Anthem, the state's largest PPO provider, said it aggressively analyzes data on claims, pharmacy services and health risks to notify members of gaps and make clinical recommendations. UnitedHealthcare said physicians now can process their claims almost immediately online, and nearly all such claims are handled within 10 days. It received one of the best overall ratings of the six major PPO companies, earning scores of good for medical care and timely access to doctors. Cigna said it has simplified its explanations of benefits to make them easier to understand to help improve customer service scores.

To learn more:
- read the Los Angeles Times article
- read the Sacramento Bee story
- see the California Department of Insurance press release

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