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Association Health Plans are coming. Right?
In early December, we were notified that the special agreement regarding out of network emergency visits between BCBST and Tri-Star Health System would expire on December 31, 2017. Previously, this agreement ensured BCBST members, with the S Network, would not be balance billed when using Tri-Star facilities in true emergency situations. The expiration of this agreement brings some uncertainty.
This is a legal battle, which puts patients squarely in the crosshairs of a fight between two large corporations. With an out of network claim, the medical provider charges whatever price they want for the services and then expects the insurance company to pay the inflated cost. This does not go over very well on the payer side and so we end up with financial battles like this.
We have dealt with this for years and can generally help our clients resolve their balance billing issues but it's never easy or guaranteed. This morning we came in to our first BCBST vs. Tri-Star balance billing issue of 2018. One of our longtime clients has an employee who was having a heart attack and was transported to the nearest hospital, Summit Hospital which is the Tri-Star facility in Hermitage. Rather than stabilize the patient and move him to an in network facility like Vanderbilt or St. Thomas, they did the heart surgery knowing it would be treated out of network. When the first bills started coming in, the hospital charges were approximately $109,000 for the surgery.
Generally, a claim like this has all the charges worked out ahead of time through the PPO network contract. When a claim is out of network, there are no set prices so the insurance company generally pays what they consider "reasonable and customary charges". In this case, BCBST paid Summit Hospital a little over $40,000 for the procedure. This amount seems reasonable to me but apparently not to Summit or Tri-Star.
This weekend the patient received a letter from Summit Medical Center requesting that he make arrangements for nearly $70,000. Needless to say, he did not have a good weekend.
What happens next? This is where two large corporations use normal working people as pawns in their multi-million dollar game of chess. They want the patient to ask BCBST to fix the problem by paying the remaining balance. Amazing for sure.
What should you do as a BCBST member when facing a similar situation? If you are having a life or limb threatening emergency, you should always go to the nearest Emergency Room to seek treatment. If you have the flu, or some other non-life threatening situation we recommend driving a little further to an in network provider to avoid this type of situation.
We expect BCBST and Tri-Star will work all this out over time. By that, we mean a number of years in which this could drag out. In the end, we really don't expect our clients to have to pay these exorbitant claims, but it will be hanging over their heads until the two companies come to a resolution. No he won't have to pay during their negotiations but it's still stressful and after dealing with a heart attack that is the last thing he needs.
It's all part of trying to keep healthcare costs as low as possible but that is never easy.