Patty Damon can see the campus of St. Anthony Hospitals Lakewood from his home, but starting in May, he may no longer be able to go there without dipping into his pockets.
Damon has insurance through Anthem BlueCross BlueShield of Colorado, which is in a dispute with the owner of St. Anthonys, CommonSpirit Health. If the two can’t reach an agreement by May 1, CommonSpirits’ 10 hospitals in Colorado will no longer be in network for the 1.5 million people covered by Anthe’s health plans in that state.
When a health center leaves the network, patients can still choose to receive care there, but the center can bill them for the difference between their charges and what the patient’s insurance is willing to pay, which could be in the thousands of dollars depending on the type of care received. Federal and state laws protect people who get out-of-network care from surprise bills in an emergency, but not when they could choose a different hospital.
Damon is scheduled for orthopedic surgery at St. Anthony in June, and she’s not sure if Shell will be able to do the procedure or if Shell needs to find a new doctor and start the process of getting on the surgical schedule all over again. Either way, Shell must find a different provider for his physical therapy after surgery if CommonSpirit goes out of network.
This doesn’t seem to be about patient care, Damon said. It’s about money, and the patient is secondary.
Representatives for both Anthem and CommonSpirit said they are optimistic they can reach an agreement by the middle of next week, but did not provide details on their negotiations. Both said the disagreement centers on tariffs.
If the two sides can’t reach an agreement, Colorado patients would have to rethink care at CommonSpirit’s 10 hospitals, eight urgent care centers, two surgery centers, seven home health providers and hospices, 26 radiology centers and five groups of doctors. The hospital St. Fort Morgan’s Elizabeth would remain on the network until mid-July, because it has a separate contract.
While patients in the Denver area have other options within a relatively short distance, patients in Summit County will have to drive to Vail or Leadville if they need non-emergency hospital care. CommonSpirit also owns Durango’s only general hospital.
Patients who are currently pregnant or undergoing treatment for a complex disease, such as cancer, could continue to go to the same location for care. However, they would have to file the refund claim themselves, according to a letter Anthem sent to its customers.
Anthem alleged that CommonSpirit had requested rate increases at more than twice the rate of inflation. CommonSpirit responded that Anthem had asked for significant rate reductions. Because the negotiations are not public, patients have no way of knowing what the truth is, or whether it may be both.
Disputes over rates are not common as both insurers and hospital chains get bigger and try to use their muscle to push for payments that benefit them. In 2021, UCHealth went out of network on Anthem plans sold in the Denver-area individual market, though the parties reached an agreement to bring them back at least a year later.
Matt Pickett, president of Colorado business plans at Anthem BlueCross BlueShield, said the insurer is still talking with CommonSpirit, but is also reaching out to customers with complex conditions to discuss their options if the split happens . If Anthem were to pay the rates CommonSpirit wants, insurance costs would increase significantly for customers and their employers, he said.
The last thing we want to do is interrupt care for these members, Pickett said. Affordability is the key issue.
Anthem recently reached an agreement with AdventHealth, the other half of the former Centura Health, Pickett said. HealthOne and UCHealth facilities will also remain in network in Colorado, he said.
Dr. Shauna Gulley, president of the tri-state medical company CommonSpirits Hospitals, said the system did not ask for payment increases that were more than twice the rate of inflation and that what Anthem was offering would not cover the increased drug and labor costs.
There is definitely a gap between reimbursement and the cost of care, he said.
CommonSpirit is focused on reaching an agreement, because in southwest Colorado, patients will face a four-hour drive for specialty care if Durango’s Mercy Hospital goes out of network, Gulley said.
It’s really about keeping doctors and patients together, he said.
Damon is considering switching insurance providers at the end of the year so he can go back to using St. Anthony, an option he acknowledges that not everyone has, as most employers only have one insurance provider. Using a different hospital won’t be a serious hardship, but it will be an unnecessary inconvenience to the person driving her to her surgery, he said.
The patient is now the pawn in this game, he said.
Subscribe to our weekly newsletter to receive health news straight to your inbox.
#Anthem #insurance #customers #Colorado #switch #hospitals #fee #dispute #resolved
Image Source : www.greeleytribune.com