Protracted negotiations between Methodist Le Bonheur Healthcare and Blue Cross Blue Shield of Tennessee have left many Memphisans wondering if their doctor might be an out-of-network provider come 2023.
If the two groups do not reach an agreement on the rates Methodist charges and the rates Blue Cross pays for both inpatient and outpatient care, it could result in tens of thousands, likely more, in the area being unable to access care medical with Methodist providers. or in a Methodist facility without substantial out-of-pocket payment.
Both sides said negotiations are ongoing and they hope to have a resolution by the end of the year.
The ripple effect of failing to reach an agreement by December 31 would not only affect the tens of thousands whose employer-sponsored health insurance comes from Blue Cross, including 14,000 covered by two city of Memphis plans. It could also affect many in the TennCare area, including children.
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Rep. Steve Cohen, D-Memphis, last week wrote a letter to Governor Bill Lee asking you to help resolve arguments. If an agreement is not reached, members of BlueCare and TennCare Select (TennCare programs administered by Blue Cross Blue Shield) could lose access to affordable treatment at Methodist Le Bonheur Healthcare System facilities. TennCare Select specifically covers children who are in foster care, have intellectual or developmental disabilities, or disabilities that qualify them for Supplemental Security Income.
From November, 178,796 people in West Tennessee were covered by BlueCare, according to the state. Other insurance companies also partner with the state to manage coverage for other TennCare members. It was not immediately clear how many of Shelby County’s 164,557 children on TennCare’s lists would be affected. Statewide, there were 53,732 people covered by TennCare Select as of November. It is not clear how many were in West Tennessee or Shelby County.
Cohen said he was particularly concerned about the impact on children with complex medical needs.
“The apparent impasse between BlueCross and Methodist Le Bonheur poses a grave risk to all TennCare recipients, but especially to children whose needs can only be met at Le Bonheur,” he wrote. “Surgeries are being (cancelled) and parents are terrified that their children will no longer be able to receive the specialized care that Le Bonheur has provided throughout their children’s lives. The situation is completely unacceptable.”
Cohen asked Lee to bring the parties together to reach an agreement, and if that was not possible, he asked the governor to direct the Division of TennCare to make special arrangements with Le Bonheur Children’s Hospital for children covered by TennCare.
Amy Lawrence, TennCare’s director of communications, said that if an agreement is reached next weekend, there will be no impact on BlueCare or TennCare Select beneficiaries. Otherwise, the department will work to avoid the expiration of the insurance.
“TennCare health plans are contractually bound to provide continuity of care and will work towards transition of care if an agreement is not signed,” Lawrence said.
Here’s what you need to know about the ongoing negotiations.
If a new agreement is not reached by the end of the year, Methodist has said it would ask the insurance provider “for an extension to minimize any disruption to our patients and their families.” If that is not agreed upon, those with Blue Cross Blue Shield as their primary insurance providers, including company-administered TennCare plans, would be treated as out-of-network patients.
While some insurance plans offer out-of-network benefits or reimbursement, seeing an out-of-network provider almost always results in much higher costs for the patient, from a standard checkup to an emergency room visit.
“Our members are free to visit the health care facility of their choice, and they can choose to continue to seek care from Methodist Le Bonheur after January 1, but they will pay more for that care,” Blue Cross said. “Our members can continue to seek in-network care with Methodist through December 31. If we can’t come to an agreement by the new year, members will continue to have in-network access to the full range of quality care from other Memphis-area providers, including Baptist Memorial Health Care system, St. Francis Hospital, and Regional One Health.”
The insurance company also emphasized that failure to settle would not affect providers who are part of Methodist Le Bonheur’s affiliated physician groups. It would only apply to Methodist facilities, Blue Cross said.
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In response to questions from The Commercial Appeal and in guest columns published in The CA, representatives from Methodist and Blue Cross found different ways of saying the same thing: The problem is money.
Blue Cross said the Methodist system charges significantly higher fees than other facilities in the Memphis area and Le Bonheur Children’s Hospital, in particular, charges notably high fees. Methodist said Blue Cross asked the hospital system to reduce fees by 40% and did not consider a counter offer, despite the level of free care it provided to the communities it served.
Methodist declined to discuss the details of the negotiations with The CA, but said its rates are fair.
“Memphis is a tight-net market where payers like Blue Cross, Cigna, United Healthcare and others negotiate rates based on covered lives that work together to reduce costs and improve quality. Methodist Le Bonheur Healthcare has a long history of providing the highest quality and safest care of any health system in this area,” the system said in a statement.
Methodist representatives, while saying they would continue to negotiate with Blue Cross, also encouraged people to “contact their human resources department and tell them they want to stay in the MLH network by switching to CIGNA, United Healthcare, or other payers who pass their savings for you.”
Blue Cross said Methodist’s latest counter offer “does not provide savings that more immediately support affordable coverage.”
“Methodist Le Bonheur Healthcare charges us significantly higher rates than other Memphis area facilities, which is ultimately unfair to our members. We are simply asking Methodist to accept fair market rates in line with the broader market in Memphis “said the insurance company. .
Corinne S Kennedy covers economic development and healthcare for The Commercial Appeal. She can be contacted by email atCorinne.Kennedy@CommercialAppeal.com