Contract clash between PMC and Regence BlueShield could upend health care for thousands of Southeast Idahoans

Thousands of Southeast Idaho residents could lose in-network access to Portneuf Medical Center and its affiliated providers by June 15 if its contract negotiations with Regence BlueShield of Idaho — one of the largest health insurance providers in the state — fail to produce an agreement.

The potential disruption would affect Regence members who rely on PMC, Pocatello Health Services, PHS Ambulatory Services and Portneuf Ambulatory Surgical Center for their health care. For Southeast Idahoans who carry Regence insurance and depend on PMC as their primary source of care the stakes are significant — losing in-network access would likely mean higher out-of-pocket costs for most non-emergency services.

Both sides have gone public with their positions — and their accounts of what is driving the dispute differ significantly. PMC contends that Regence reimburses the health system at unfairly low rates compared to other insurers and has created mounting administrative barriers that delay patient care. Regence counters that PMC's parent company — Tennessee-based Ardent Health — is demanding double-digit rate increases that would ultimately drive up costs for local businesses and health plan members.

The state is monitoring the situation and the Idaho Office of Group Insurance sent an email Friday regarding the contract dispute.

"These negotiations are being conducted on Portneuf’s behalf by executives of Ardent Health, a Tennessee-based, private-equity-backed, for-profit healthcare organization that jointly operates and manages Portneuf," the Idaho Office of Group Insurance stated. "According to Regence, Ardent’s initial proposal sought a 73% increase in healthcare costs over seven years. Their most recent proposal reflects a 41.6% increase over five years. Regence has indicated that increases of this magnitude, more than double the rate of inflation, could lead to substantial and unsustainable premium increases for members."

But PMC says the dispute goes far beyond reimbursement rates — though rates are a central concern. According to PMC, Regence reimburses the health system significantly less than other major insurers in the market and less than it pays many other Idaho health systems. PMC says it is seeking a fair agreement that helps narrow that gap and supports the long-term sustainability of care in the community.

But PMC says the problems run deeper than rates alone. In addition to reimbursement concerns, PMC cited what it described as growing administrative challenges including unpaid claims, claim denials, down coding and repeated reprocessing requirements — issues it says have increased administrative burden and delayed patient care.

"This is not simply a dispute over rates," PMC said in a statement. "It is about whether Regence is willing to support the staffing, services, and infrastructure needed to maintain a strong local health system for its members."

Regence tells a different story about who is driving the potential disruption. In a statement released April 24 Regence said PMC's parent company, the "for-profit Ardent Health," is demanding double-digit reimbursement rate increases, which Regence described as more than twice the rate of inflation.

"As your local, nonprofit health plan, our premiums directly reflect the prices provider systems charge for health care," Regence said. "While we are open to negotiating increases, we cannot accept the rates currently being demanded by Ardent Health's executives."

Regence framed the potential departure as PMC's choice rather than a negotiating failure — saying PMC's leaders have informed Regence that they wish to end their contract if their demands are not met. The insurer pointed out that it invests 87 cents of every premium dollar directly into members' health care and argued that accepting PMC's demands would drive up costs for local businesses and health plan members.

Emergency care would not be affected by a contract breakdown. Both sides confirm that federal law requires emergency services to be covered at in-network rates regardless of whether a contract is in place. Patients who are pregnant or undergoing active treatment for serious conditions may also qualify for continuity of care coverage under the No Surprises Act — both PMC and Regence are encouraging affected patients to call the number on the back of their insurance card for details.

Regence has identified alternative in-network providers for members who may need care if PMC goes out of network. In-network hospital options include Bingham Memorial Hospital in Blackfoot, Caribou Medical Center in Soda Springs, Mountain View Hospital in Idaho Falls and Idaho Falls Community Hospital. In-network primary care and multispecialty clinic options in the Pocatello area include Bingham Memorial Clinics, MVH Physicians Immediate Care, Brandon A. West Clinic, Health West and Family Practice Group. Several virtual care providers are also available in the Regence network. Members with questions can call the number on the back of their Regence member ID card or visit regence.com.

PMC is encouraging Regence members who want to maintain in-network access to its facilities to contact their employer or insurance broker about plan options that include PMC as an in-network provider. A full list of insurance plans accepted at PMC is available at portneuf.org/insurance.

The Idaho Office of Group Insurance said in its email: "While this situation is concerning, both Ardent and Regence have stated they are continuing to negotiate in good faith and remain hopeful that a fair agreement can be reached. In the meantime, we are working closely with our Regence account team to ensure that impacted State of Idaho members have access to clear information, including alternative providers and facilities, should an agreement not be finalized."

Both Regence and PMC say they remain committed to reaching an agreement — but the June 15 deadline is approaching and the gap between their positions remains significant. For the thousands of Southeast Idaho residents who rely on PMC for their health care and carry Regence insurance the outcome of these negotiations matters enormously.