Blue Cross and Blue Shield of Illinois, which has agreed to pay a $339,000 state fine stemming from the insurer's almost year-long contract dispute with Springfield Clinic, says the clinic is making unreasonable demands.Blue Cross divisional senior vice president Krishna G. Ramachandran said the for-profit, multi-specialty clinic, in its "first very specific counter-offer," is demanding a 75% increase in reimbursement rates "even though their rates are already the highest in the Springfield market and tower 60% more than those in the Chicago market."
Ramachandran made the statement in a Guestwork piece published in the March 24 edition of Illinois Times. The company wouldn't provide the data upon which its assertions were based. The aggressive stance by Chicago-based Blue Cross, the state's largest insurance company, comes as thousands of central Illinois patients deal with the ramifications of Blue Cross removing the clinic's doctors and other medical providers from the insurer's preferred-provider network last summer and fall.
Illinois' insurance department is evaluating whether Blue Cross' remaining central Illinois provider network meets adequacy standards without Springfield Clinic's more than 600 medical providers. Department officials said the fine was based on Blue Cross failing to notify the department that the removal of the clinic was a "material change" in the network that justified the insurer filing documents proving adequacy.
The fine was issued amid reports that Blue Cross' online listing of network doctors and other providers wasn't up to date. Some patients say they have had to leave longtime doctors at the clinic to avoid higher out-of-pocket costs and faced long waits for appointments at other medical practices.
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 they faced stressful bureaucratic hurdles to get extensions, were granted extensions for only a few weeks or a few months at a time, or were denied in-network coverage.
Still other Blue Cross-insured patients say they have postponed getting care outside of Springfield Clinic in hopes the dispute will be resolved. There's no resolution in sight, however. Colleen Miller, spokeswoman for Blue Cross's parent company, Chicago-based Health Care Service Corp., said March 29 that HCSC paid the penalty assessed by the state. She wouldn't say why the company decided not to dispute the fine, the first issued since the state's Network Adequacy and Transparency Act took effect in 2019.
She did say Blue Cross is "taking the opportunity to explain our position" to the state and "is committed to working with the state and looks forward to further clarify around how it applies and enforces these rules." HCSC operates Blue Cross plans in Illinois, Texas, Montana, New Mexico and Oklahoma.
HCSC posted $45.9 billion in revenues in 2021 and $1.2 billion in profits, representing a margin of 2.6%. Illinois Times asked Springfield Clinic for a response to Ramachandran's letter and specifically his statements about Springfield Clinic's reimbursement rates and the clinic's proposed rate increase. Clinic spokesman Zach Kerker responded with an emailed statement.
"Central Illinois is not Chicago," he wrote. "We have strong relationships with more than a dozen commercial insurance companies that recognize the value and quality of care that Springfield Clinic provides to our patients. BCBS is the only insurer that jeopardizes access to that care by significantly undervaluing our market to increase its own profits. Thankfully, there are laws in place to protect employers and patients from the very type of 'ghost networks' that have recently been exposed, and we applaud the Department of Insurance for working to uphold the law."
Springfield Clinic has declined to provide data supporting its statement that Blue Cross is jeopardizing access to care from clinic providers. Illinois State Medical Society President Dr. Regan Thomas said in a statement that the state fine "is a critical first step for ensuring patients get the access to medical care they deserve. "The practice of 'ghost networks' must end. Insurance company provider directories often list doctors who are unavailable, not taking new patients, are located far away or who don't work at the listed medical facility, or are no longer a part of the network."
State Rep. Sue Scherer, D-Decatur, who said many of her constituents have lost access to their regular doctors because of the contract dispute, on March 23 introduced House Bill 5729, which Gov. JB Pritzker said would "make our system operate more transparently and give people and regulators more tools to hold health care insurers accountable."
Officials at the insurance department, which is controlled by the Democratic governor, said the bill would put in place more stringent standards for network adequacy to make sure patients don't have to travel long distances to reach medical providers. The bill hasn't been considered yet by the House or Senate. The legislation would give state officials the ability to tell consumers when an insurance company's actions are being investigated as part of a "market conduct exam."
When asked Blue Cross' view of the bill, Miller said, "We welcome efforts to offer clarity around laws that impact our industry and how we can best serve our members." Miller said Blue Cross "has begun proactive outreach to the 1,400-plus members approved for continuity of care with the Springfield Clinic. Our staff are calling to let those members know we'll be reviewing all their claims to ensure we're managing those claims properly. We'll also be sending out letters with the same message."
Miller said Blue Cross has set up a new phone line, 877-325-2958, for members with questions about how Springfield Clinic's network status affects their coverage. The line will be answered from 8 a.m. to 5 p.m. Monday through Friday. Chatham resident Joe Vallar said his family has dealt with stress, administrative headaches, hours on the phone with Blue Cross and uncertainty about out-of–pocket expenses associated with his wife's treatment for breast cancer from Springfield Clinic.
The treatment began in March 2021 and continues, he said. Joe Vallar, 38, gets Blue Cross insurance for himself, his wife and their four sons through his job as a first-responder. Vallar said he and his wife, Sara, 37, trust their clinic doctors and have been upset with Blue Cross because of delays, uncertainty and occasional denials from Blue Cross for continuity of care to preserve in-network coverage.
"It's been a lot of phone calls and a lot of paperwork," he said, adding that he has refused Blue Cross' suggestion that he switch his wife's cancer care to doctors outside the clinic. "I wasn't willing to risk my wife's life over something petty that's going on," he said. "Springfield Clinic has been nothing but wonderful to us."
Vallar said he blames Blue Cross for the additional stress 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. "It's asinine. It's wrong," he said. "I'm paying a premium for a reason. You're playing with my wife's life."
Dean Olsen is a senior staff writer for Illinois Times. He can be reached at [email protected] or 217-679-7810.