Blue Cross and Blue Shield of Illinois claim that Springfield Clinic is making unreasonable demands in order to settle a contract dispute that has been going on for almost a year, which has resulted in a fine from the state of Illinois of $339,000 and criticism from patients.
According to Blue Cross divisional senior vice president Krishna G. Ramachandran, the for-profit, the multi-specialty clinic is demanding a 75% increase in reimbursement rates in its “first very specific counter-offer,” even though the clinic’s rates are already the highest in the Springfield market and tower 60% more than those in the Chicago market.
This assertion was stated by Ramachandran in a Guesswork article that was included in the edition of the Illinois Times dated March 24. The corporation refused to give the data on which its assertions were based, thus those assertions cannot be verified.
The aggressive stance taken by Blue Cross, which is headquartered in Chicago and is the largest insurance provider in the state, comes at a time when thousands of patients in central Illinois are dealing with the ramifications of Blue Cross removing the clinic’s doctors and other medical providers from the insurer’s preferred-provider network during the summer and fall of last year.
The Illinois Department of Insurance is currently conducting an investigation to determine whether or not Blue Cross’ remaining central Illinois provider network satisfies adequateness standards in the absence of more than 600 medical professionals associated with Springfield Clinic.
Officials from the department stated that the charge was levied because Blue Cross did not tell the department that the elimination of the clinic constituted a “substantial change” in the network that necessitated the insurer filing paperwork establishing adequacy. This was the reason for the fine.
In light of complaints that Blue Cross’ online listing of network doctors and other providers did not reflect the most recent information, the company was fined.
Some patients have said that in order to avoid incurring higher out-of-pocket payments, they were forced to stop seeing their long-term doctors at the clinic, and they also experienced lengthy waits for appointments at other medical clinics.
Other patients who were granted “continuity of care” extensions by Blue Cross for temporary in-network benefits for pregnancy or life-threatening conditions have said that they had to overcome stressful bureaucratic hurdles in order to get extensions, that they were only granted extensions for a few weeks or a few months at a time, or that they were denied in-network coverage. Blue Cross has been under scrutiny for its treatment of patients who were granted “continuity of care” extensions.
Still, some Blue Cross-insured customers have said that they have delayed receiving treatment from providers other than the Springfield Clinic in the hopes that the disagreement will be addressed.
However, there does not appear to be any way out of this predicament.
The Illinois House committee hearing scheduled for March 22 to discuss how the situation has impacted health coverage in the region has been postponed or canceled. The hearing that was originally planned to take place in front of the House State Government Administration Committee will now take place on March 30 at 3:00 p.m. in Room 114 of the Capitol Building and online at ilga.gov.
The parent company of Blue Cross, Health Care Service Corp., based in Chicago, has not yet determined whether or not it would contest the fine that was issued by the Illinois Department of Insurance. This is the first time that the state has levied a punishment under the Network Adequacy and Transparency Act, which went into effect in 2019.
Blue Cross plans are administered by HCSC in the states of Illinois, Texas, Montana, New Mexico, and Oklahoma. In 2021, HCSC reported revenue of $45.9 billion and earnings of $1.2 billion, resulting in a margin of 2.6%.
In light of Ramachandran’s letter and, more specifically, his assertions regarding Springfield Clinic’s reimbursement rates as well as the clinic’s anticipated rate hike, Illinois Times contacted Springfield Clinic to inquire about a response to the letter.
A comment was issued to us in response to the clinic’s spokesman, Zach Kerker.
He wrote that Central Illinois was not the same as Chicago. “We have great connections with over a dozen commercial insurance companies that appreciate the value and quality of care that Springfield Clinic gives to our patients. These insurance companies work closely with us to ensure that our patients receive the best possible treatment.” The only insurer that puts patients’ access to treatment at risk by severely undervaluing our market in order to boost its own profits is BCBS. We are thankful that regulations have been passed to protect companies and patients from the “ghost networks” that have lately come to light, and we commend the Department of Insurance for its efforts to uphold these rules.
The Springfield Clinic has indicated that it will not be providing any data to back up its claim that Blue Cross is putting patients’ access to care from clinic clinicians at risk.
Dr. Regan Thomas, president of the Illinois State Medical Society, issued a statement in which he referred to the state’s fine as “an essential first step” for ensuring that patients have access to the kind of medical treatment that they merit.
“It is time to put an end to the practice of ‘ghost networks.’ Directory listings provided by insurance companies frequently include physicians who are either unable to treat patients, do not accept new patients, do not work at the given medical institution, are situated in remote areas, or have left the network entirely.
On March 23, State Representative Sue Scherer, a Democrat from Decatur, introduced House Bill 5729. She stated that many of her constituents have lost access to their regular doctors as a result of the contract dispute. Governor JB Pritzker stated that the bill would “make our system operate more transparently and give people and regulators more tools to hold health care insurers accountable.”
According to officials at the insurance department, which is controlled by the Democratic governor, the measure would put into place more severe rules for network adequacy to ensure that patients do not have to travel for a significant amount of time in order to contact their medical providers.
Neither the House nor the Senate has taken any action on the bill as of yet.
Because of this proposed piece of legislation, state regulators would be granted the authority to inform policyholders if the acts of an insurance provider are being scrutinized as part of a “market conduct exam.”
Colleen Miller, a business spokeswoman for Blue Cross, was asked about the firm’s position on the bill, and she responded by saying, “We encourage attempts to bring clarity about regulations that affect our sector and how we can best serve our members.”
Considering that this year is an election year for Pritzker and all members of the General Assembly, the matter has taken on a more political complexion.
The campaign of Aurora Mayor Richard Irvin, who is running for the Republican nomination to challenge Pritzker in the fall election, stated that the Pritzker administration “continues to slow roll its response in holding Blue Cross-Blue Shield accountable.” Irvin is running for the Republican nomination to challenge Pritzker in the fall election.
Irvin’s campaign said Pritzker should curb Blue Cross’ enrollment in the short term and urge Blue Cross to evaluate “continuity of care” claims that the insurer has denied.
Pritzker’s campaign didn’t reply to a request for comment.
According to Miller, Blue Cross “has initiated aggressive outreach to the more than 1,400 members who have been approved for continuity of treatment with the Springfield Clinic.” Our staff will be contacting those members to let them know that we will be evaluating all of their claims to verify that we are appropriately managing those claims. In addition to this, we will be disseminating the same information through letters.
Miller stated that Blue Cross has established a new phone line with the number 877-325-2958 for members who have queries regarding how the network status of the Springfield Clinic affects their coverage. Monday through Friday calls to this number will be handled between the hours of 8 a.m. and 5 p.m.
Joe Vallar, a resident of Chatham, said that his family has had to cope with stress, administrative headaches, hours spent on the phone with Blue Cross, and uncertainty regarding the out-of-pocket payments related to his wife’s treatment for breast cancer at Springfield Clinic. According to him, the treatment had its beginning in March of 2021 and will continue.
As a result of the work that Joe Vallar, age 38, does, he and his family, which includes his wife and their four children, are all covered by Blue Cross insurance.
Vallar and his wife, Sara, who is 37 years old, are both angry with Blue Cross because of the delays, ambiguity, and occasional denials from Blue Cross for continuity of care to keep in-network coverage. According to Vallar, he and his wife both trust the doctors at their clinic.
“It’s been a lot of phone calls and a lot of paperwork,” he said, adding that he has rejected Blue Cross’ proposal that he move his wife’s cancer care to doctors who are not affiliated with the clinic. “It’s been a lot of phone calls and a lot of paperwork,” he said.
He stated, “I wasn’t willing to endanger my wife’s life over anything silly that’s going on,” which translates to “I didn’t want to put my wife in danger.” “Our interactions with Springfield Clinic have been nothing but positive.”
Vallar stated that he blames Blue Cross for the added hardship that his family has dealt with when it comes to paying for his wife’s care, which has included 14 rounds of chemotherapy and 37 rounds of radiation treatment. Vallar’s wife has been treated with both chemotherapy and radiation.
“That’s ludicrous. “You’re doing it incorrectly,” he remarked. There’s a good reason why I have to pay a higher premium. You are putting my wife’s life in danger by doing that.