Aetna severs contract with Simi Valley Hospital [Ventura County Star, Calif.]

April 10--For the second time in five weeks, a dispute between a hospital and an insurance company threatens to push some Ventura County residents elsewhere for care.

Aetna officials confirmed Monday that the health insurer had terminated its contract and stopped negotiations with Simi Valley Hospital and several other hospitals operated by the Adventist Health System.

The stalemate means Aetna members will have to pay higher, out-of-network rates to receive care at the hospital unless a new contract is reached. The insurer covers 16,332 people in Ventura County.

Temporary coverage, however, will be extended to people including pregnant women, many children 3 and younger and patients with terminal, acute and some chronic illnesses, said Simi Valley Hospital spokeswoman Alicia Gonzalez. Procedures already authorized by Aetna will also be covered, and people can seek emergency care regardless of insurance coverage.

In March, Anthem Blue Cross severed its contract with Los Robles Hospital and Medical Center in Thousand Oaks. Last week, hospital officials announced the two sides had reached an agreement, meaning Anthem members were again covered.

"It's just the nature of the beast these days," said Dr. Harris Wasser, a Simi endocrinologist, suggesting insurance disputes are common. He's advising his Aetna patients to take a wait-and-see attitude to see if the insurance company and hospital can come to an agreement.

"It all depends on how badly that insurance (company) needs that facility," he said.

Helene Vallow and husband Gary, both in their 60s, live in Simi Valley and are covered by Aetna. The termination means they won't be covered for lower rates at the hospital, the Aspen Surgery Center or the Nancy Reagan Breast Center.

"It's horrible," she said. "It's very inconsiderate and it's all about the money. I think both sides are at fault."

Aetna officials say they want to lower their reimbursement rates for Simi Valley Hospital and several other Adventist hospitals.

"When comparing services and complexity of cases, Adventist is more expensive for our members compared to other participating hospitals," Aetna spokeswoman Anjie Coplin said in a written statement. "Our job is to help control health care costs for our customers and members. When charges are exorbitant, we must take action to protect our customers and members."

The rate reduction would hurt Simi and other hospitals, Gonzalez said in a written statement, contending the insurance company has a "favorable" payment rate for acute care services but still demanded a reduction.

"We are unwilling to compromise on the quality of care that our patients expect and deserve," she said, also contending Aetna plans cuts in physician fees. "We must have insurance contracts that provide fair, reasonable and timely payment for the services we provide."

Other area Adventist Health hospitals terminated by Aetna include Glendale Adventist Medical Center, White Memorial Medical Center in Los Angeles and San Joaquin Community Hospital in Bakersfield.

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