Progress made on ER insurance gap

Baptist Health South Florida and its independent ER physicians' group, SHI Keys, announced this week that an agreement has been reached whereby SHI Keys would now accept Florida Blue (BCBS) and Cigna healthcare insurance as in-network plans.

Amid mounting pressure from Monroe County, Keys residents and recent media coverage, the two groups have quickly bridged part of the gap that placed large, out-of-network expense on many Monroe County ER patients. As of press time, two additional health care plans - Aetna and United Healthcare, which are carried by many Keys residents - are still not accepted by SHI Keys.

Both Fishermen's and Mariners Hospitals accept all four of those plans for hospital services.

In a statement released by BHSF and SHI, which appeared as an advertisement in the Oct. 13 edition of The Key West Citizen's sister paper, the Florida Keys Free Press, both admitted that "physician groups who are contracted to see patients at Baptist Health facilities should be in-network with the same insurance companies as the facilities", and that they "were recently made aware of patient billing concerns related to SHI Keys out-of-network status with several insurers that serve Monroe County." However, the SHI contract with BHSF has been in place since early 2021.

Bryan Cook, Director of Employee Services handling Human Resources for the county, stated last week when the contract between BHSF and SHI was signed, "it would have been better if BHSF would have looked at the local market and the customer base and required a stipulation to the physician's group to accept the insurances in this market".

Cook said in an email: "Being able to easily and understandably utilize medical insurance to access healthcare is important for everyone in the Keys. Baptist Health and the SHI Keys physicians group quickly responded to the oversight as soon as it was identified. I'm pleased with how all parties have worked together to quickly install health insurance networks, address billing concerns, and establish customer service options to assist all of our residents."

Cook is trying to solve this on both the county employee front and for all county residents who are affected. He estimated last week that there are upwards of 2,300 Monroe County employees, family members and retirees covered by the Florida Blue plan, which also includes employees and families of businesses and municipalities outside the Monroe County umbrella, such as the Florida Keys Aqueduct Authority, Keys Energy Services, the City of Marathon and the Village of Islamorada, as well as other county subsets such as the Monroe County Sheriff's Office.

Cook confirmed these four healthcare plans are the most widely used in the county. But he added, "I don't know how many people there are who work in the Monroe County School District, the FKAA and all these other affected employers who will have these same problems."

However, despite the resolution, the fallout for Monroe County employees and residents may continue until each claim is resolved. Cook estimated the county has at least 55 cases where its employees since Jan. 1 have had problems with coverage. He has been advocating to resolve this for county employees but said it will be a slow process.

Even with Cook's efforts, many county residents may be on their own to resolve their individual insurance claims. Private duty nurse Rebecca Lundy, who lives in Key Colony Beach and has worked in an ER trauma center in the past, is one who has been dealing with such a difficult insurance situation of her own for months.

Lundy is on her husband's BCBS insurance plan and in June went to Fishermen's Emergency Room with severe kidney stone pain. After the ER physician on staff that day said the ER had no anesthesiologist on hand or a urologist on call, she was given morphine for the pain and sent home.

She ended up going to Key West Surgery Center and had a stent inserted, which relieved her pain. Shortly thereafter, Lundy received a bill from SHI for $2,092. The explanation of benefits she received from BCBS was that the ER doctor who tended to her was out-of-network and asked her to submit an appeal letter. Now that SHI is accepting BCBS, she wants to make sure this change is retroactive for her. She assumed when she arrived at the ER in unbearable pain that BCBS would be accepted and figured, at least in the discharge paperwork, there should have been some specific information on insurance coverage. There was none.

Monroe County Mayor Michelle Coldiron said in a Zoom call this week that she first learned of this situation from social media and immediately brought it to the attention of Cook, who had just been made aware. She lauded Cook's efforts on behalf of county employees and residents.

Coldiron also spoke with both Fishermen's Foundation Chair and attorney Jay Hershoff and Hospital CEO Drew Grossman, who told her that BHSF couldn't negotiate private contracts with each insurance provider, but that it was SHI's responsibility to conduct that. However, an out-of-market hospital administrator confirmed it was customary for both parties to handle in-network contracts when contracts are signed.

Coldiron's goal for inviting BHSF to the Wednesday, Oct. 20, BOCC meeting to address the situation is for "transparency," she said. She recognizes that some residents remain indignant about the Middle Keys special taxing district, which is funding Baptist's rebuild of Fishermen's, and hopes both Fishermen's and Keys residents can "go back to getting along again." She expects Hershoff and Grossman to attend that session.

According to Monroe County, $2.25 million has been paid to Baptist Health from the Middle Keys Health Care taxing district since its inception. The Marathon City Council votes every year to continue or cut annual funding, with the next vote in February.

Also in the advertisement, it states that "balance billing will not occur" and that "patients of SHI Keys physicians in Monroe County will not pay more for emergency services out-of-pocket costs than what's indicated by their insurer."

Balance billing is where providers bill a patient for the difference between the amount they charge and the amount the patient's insurance pays. The amount that insurers pay providers is almost always less than the providers' "retail price." Some providers, as in this case, SHI Keys, bills the patient for the difference, or balance.

In an email from Ruddy Valdes, President of SHI, he said, "We do have agreements in place with Florida Blue and Cigna, and we are in active negotiations with Aetna and United. With regards to balance billing - I can assure you that it will not occur. We are reviewing all patient files and communicating directly with patients who have concerns." He recommended anyone who has a concern call SHI directly at 386-516-5582.

Cook said BHSF recommends that Monroe County residents who have questions regarding their coverage, including the cost of an upcoming procedure, should contact Baptist's Central Pricing Office at 786-662-7181.

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