HealthNet of AZ, Inc. First Health (Coventry, Inc.) Guess what your plan is and Guess who in California is an In-network provider Tempe, Arizona

When I lived in Arizona, I bought a HealthNet of AZ, Inc. PPO insurance plan, selected by a broker, Roger Walker, that was supposed to fit my needs, including a future contingent event that I might move back to California and desired a plan that would provide reasonable coverage until I reached the age for MediCare coverage.   (2006)   In 2008, I went in person to Palo Alto Medical Foundation-Fremont Center (PAMF) to find out if they accepted my insurance or not.   My family doctor and my family's family doctor worked there for many years, and I presented my insurance card, was asked the name of my primary doctor and was told she was a "First Health provider", which I was told meant she was a Health Net provider because First Health is the name Health Net uses in California for my plan.   First Health, according to Health Net of AZ, is actually a third party vendor, but from my point of view, if Health Net of AZ opts to use a third party to provide me access to in-network coverage, it is responsible to me for delivery of what was implicitly promised when I bought this insurance.   In 2009, I had an annual exam with diagnostic tests and Health Net of AZ treated all expenses as out-of-network expenses based on First Health's representations or lack of representations to Health Net.   I paid PAMF only a small amount based on an in-network plan amount and challenged the balance due by not paying it and pursuing the issues involved to remedy the problem of being offered in-network services by the provider PAMF, and ending up with out-of-network services instead by First Health-Health Net.   Apparently, there were a lot of surprised patients with First Health-based problems.   PAMF's billing staff got upset when I told them what First Health reps told me, i.e. that there was no contract for in-network services with PAMF, but they had contracted with a few of the physician-employees to provide in-network services.   PAMF's staff said PAMF is one taxpayer with one I.D. so they either are, or are not, an in-network service provider.  However, Health Net was supposed to decide on what days PAMF was an in-network provider.  The date June 1 for 2009 was apparently agreed upon, after two of my claims went six months unprocessed.  A behind-the-scenes fight began due to First Health's fraudulent representations about the physician-employees who worked at PAMF, which is visible by changes to the internet site by First Health, but no change in their policy of not listing the names of certain contracted entities.  PAMF's staff's point of view helped me recognize something odd I missed:  On claims not paid (without IRS Form 1099-Misc filing requirements), the names of employee-physicians appear as the claimant, but on another claim paid as in-network, the name of PAMF appears.  There appears to be a rhyme and reason for the inconsistency.  One of the tricks First Health is using is to not disclose who in actual fact has the in-network service agreement with them, and fabricating a website to lead consumers astray because they can list primary care physicians and not list the doctors they can predict will do the diagnostic services.  As a patient, I cannot know which doctor in PAMF will read my mammography, or my pap smear, or my blood test.  The PAMF billing persons who saw a lot of bills were not surprised the diagnostics were not paid, but were very surprised Health Net did not pay the office visit for the annual exam for this particular physician because usually it was paid.  That gave me a clue to understand better the First Health business design.   It never occurred to me that an insurance company could treat an employee-physician the same as a sole practitioner for insurance purposes.  I believe under the facts and circumstances, this is illegal and fraud.  I called First Health who told me I should get the equivalent of a Rx for diagnostic services in the future and go to their in-network outside providers, but under my plan, in 2009, if PAMF is a contracted party for in-network services, the plan's booklet applies, which means, Health Net of AZ is potentially liable to pay for all the benefits in the booklet, and the medical provider is not responsible to know, or contract, according to that booklet.   It is Health Net of AZ's responsiblity to make sure First Health does not arbitrarily and capriciously make up fiction to justify the practice of cutting up a practice into pieces to transform in-network services into partially out-of-network services to suit the insurance companies to disguise agreements made that do not "fit" the plan benefits offered.   This becomes a consumer trap with consumers caught between two misfitted "cookie cutters".  PAMF's admin staff told me there is no detailed contract that gives First Health the authority to do this and dissimulate misinformation that incorrectly designated PAMF as NOT AN IN_NETWORK PROVIDER, and designate its physicians as IN_NETWORK PROVIDERS, unless all physicians are listed, rather than solely selected at the discretion of First Health.   First Health appears to be doing a "clean up" sweep, but what other in-network providers is First Health covering up, so insured people will not know that they can challenge this system by challenging the medical practices who hold themselves out as accepting insurance plans like this, so they will challenge the insurance companies, if you hold them accountable for what you, the patient, relied on in good faith.   Given all the insurance plans and insurance companies there are, providers may be making offers "in the blind", not knowing the consequences.  The same applies to insured persons, who buy "in the blind" with insuffient simple information that no sales agents are willing to give us.  I wrote to the physicians whose names appeared on Health Net's Explanation of Benefits to tell them that Health Net had represented to me that they, as individuals, have filed (fraudulent) claims for benefits against my insurance policy, (which I believe individual employees cannot do).  These physicians never file insurance claims, but  I believe PAMF's Administration heard their complaints also.  Based on what I observed, I believe Health Net misinterpreted the information to serve its own needs, but I think the line was crossed to create fraudulent representations on an E.O.B. to me, the insured.  I filed an appeal, as best I could, and Health Net called me at home before writing a response.  I told them I did not see the employee-employer issue, but PAMF did catch First Health's erroneous representations of the facts.  Health Net of AZ staff stated in writing that through First Health it had contracts with the two individual doctors and with PAMF.  It seems the staff says her contract with First Health and Health Net's contract with First Health et cetera, which is a nonsensical form of language, in my opinion, designed not to pop the illusions First Health is creating through use of the internet and phone call reps who think the computer screen perfectly reflects reality to them, that they simply need to justify as real to whoever calls, and not investigate if it is real, or has errors.  This is convenient for First Health to operate deceitfully and just blame its phone persons for errors, or argue these errors are just "isolated" errors.  There is nothing I found to support the errors are limited, and non-consequential to me.  However, how can an insurance company choose to believe nonsense and just say this is true because it was represented to us to be true.  That violates a basic employee moral obligation to reject obvious mistruths, or investigate inconsistencies, so as not to repeat untruths to one's insured,  but employees have conflicts of interests i.e. keeping one's job or getting promoted.    I am so tired of being ripped off by large institutions who know how to withhold simple and basic information that consumers need to manage our own personal business in a reasonable manner.  It took me five months to sort through ambiguities, incomplete and misleading representations, conflicting representations, to identify a few issues that at least can make some people uncomfortable about how they do business, so perhaps they will change, and remember we are all consumers.  I thank PAMF for remembering that they are a not-for-profit entity whose mission is to serve the members of the local community.  PAMF has to cover its expenses, and so does Health Net of AZ.   However, each party, including myself, needs to be held accountable for what one reasonable is accountable for, and conflicts of interest should exist at all points, or as a consumer/insured, I will again face a bill I cannot afford to pay, an unexpected bill, when I tried my best to avoid this, and I am frustrated with what appears to be a deteriorating concept of what a good insurance plan is.   I hope insurance companies can make a good profit by offering a good insurance product that fits consumers needs better, is fairly disclosed, creates "peace of mind", which is about risk management, and put some money in reserve, so if I have claims, they can pay them.  However, I would not mind to see First Health, the First Health Network, and the parent Coventry, Inc. (who seems twice the size of Health Net, Inc.) be held responsible to pay for whatever claims by other insurance companies who relied on their representations were erroneously processed due to First Health's own erroneous representations or faulty lack of representation of relevant in-service provider's names.   The Health Net of AZ PPO plan as a national plan is really dysfunctional because the First Health insurance service includes providing to Health Net  "out-of-service" claims with the insured supposedly at fault for their bad decisions to listen to First Health's false and misleading info or First Health Network "contracted" medical providers, taking actions based on bad or no information given, or the medical providers blaming the insurance companies.  Given my level of income, it seems I can bargain a better rate for medical costs with providers, if I dump this liability:  junk insurace.  I cannot afford to waste my money on affordable junk insurance today.  Can you?  Maybe that is information insurance companies need to hear from consumers so they and their sales agents can clean up their act for tomorrow.  Perhaps Health Net is as gullible as I was and allowed sales of badly designed and mis-modeled insurance plans that now need to be recalled like bad autos and be recrafted to meet minimum standards of insurance, including disclosure standards, so as not to erode consumer confidence in the insurance industry as a whole.  What I really find annoying about the individual PPO plans in general is they turn the insurance companies into some sort of big brother who is going to negotiate fees for their insured persons, attempt to dictate, but fail to convey what consumers need to know to help control costs:  What providers charge too much, or fluff their bills with non-existent or questionable "add-on" services, or do not actively help patients by offering risk analysis of opting out of diagnostic tests, or by a policy of who knows what or how the insurance companies pay???, so whatever the insurance company does not pay, the patient pays.   What happened to the insurance concept of reasonable and customary fees?  It gets lost.  Who wants to sign a blank check?