Protracted negotiations between Methodist Le Bonheur Healthcare and Blue Cross Blue Shield of Tennessee have left many Memphians wondering if their doctor will become an out-of-network provider when 2023 rolls around.
If the two groups do not reach an agreement on the rates charged by Methodist and the costs paid by Blue Cross, both for inpatient and outpatient care, it could result in tens of thousands ― most likely ― in the area who would not be able to access health care with Methodist providers. or in a Methodist area without a large out-of-pocket payment.
Both sides said that negotiations are still ongoing and they hope to have a solution by the end of the year.
The ramifications of not reaching an agreement by Dec. 31 will not affect tens of thousands of employer-sponsored health insurance through Blue Cross, including 14,000 covered by two City of Memphis plans. It can also affect many in the area covered by TennCare, including children.
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Rep. Steve Cohen, D-Memphis, last week wrote to Gov. Bill Lee’s letter asking him to help resolve the negotiations. If an agreement is not reached, BlueCare and TennCare Select enrollees ― TennCare plans managed 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 an intellectual or developmental disability or have a disability that qualifies them for additional coverage.
As of November, 178,796 people in West Tennessee were covered by BlueCare, according to the state. Some insurance companies also partner with the state to offer TennCare to some enrollees. It was not immediately clear how many of Shelby County’s 164,557 children enrolled in TennCare would be affected. Statewide, there were 53,732 people covered by TennCare Select as of November. It’s unclear how many were in West Tennessee or Shelby County.
Cohen said he is particularly concerned about the impact on children with complex health needs.
“The disagreement between BlueCross and Methodist Le Bonheur poses a serious risk to all TennCare recipients but especially to children whose needs are not being met at Le Bonheur,” he wrote. “Surgeries are being canceled, and parents are afraid that their children will no longer be able to receive the special care that Le Bonheur provides throughout their children’s lives. The situation is totally unacceptable.”
Cohen asked Lee to bring the parties together to reach an agreement and, failing that, 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, director of communications for TennCare, said if an agreement is reached next weekend, it will not affect BlueCare or TennCare Select recipients. Otherwise, the department will work to avoid the expiration of the insurance.
“TennCare health plans are required by contract to provide continuity of care and will work on transitional care if the agreement is not signed,” Lawrence said.
Here’s what you need to know about ongoing negotiations.
If no new agreement is reached by the end of the year, Methodist said it will 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 provider ― 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 higher costs for the patient for everything from routine checkups to emergency room visits.
“Our members have the freedom to visit the health care facility of their choice, and they can choose to continue seeking care at Methodist Le Bonheur after Jan. 1 — but they will pay more for that care,” Blue Cross said. “Our members can continue to seek in-network care with Methodist until Dec. 31. If we can’t reach an agreement in the new year, members will continue to have in-network access to the full range of quality care from other Memphis-area providers including the Baptist Memorial Health Care system, St. Francis Hospital and Region One Health.”
The insurance company also stressed that failure to reach an agreement would not affect providers that are part of Methodist Le Bonheur’s member physician groups. It will only work in Weseli centers, said Blue Cross.
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In response to questions from the Commercial Appeal and two guest columns published in CA, Methodist and Blue Cross representatives found different ways to say the same thing: money is the problem.
Blue Cross said the Methodist system charges much higher than other facilities in the Memphis area and Le Bonheur Children’s Hospital, in particular, charges the highest. Methodist said Blue Cross asked the hospital system to lower rates by 40% and did not consider the opposition, despite the level of free care it provides to the communities it serves.
Methodist declined to discuss details of negotiations with CA but said its rates are fair.
“Memphis is a small network market where payers from Blue Cross, Cigna, United Healthcare and others negotiate prices based on integrated health that work together to reduce costs while improving quality. Methodist Le Bonheur Healthcare has a long history of providing the highest quality and safest care in any other health system in this area,” the system said in a statement.
Methodist representatives, while saying they will continue to negotiate with Blue Cross, also encouraged people to “contact your human resources department and tell them you want to stay in the MLH network by switching to CIGNA, United Healthcare or other payers.” the money you set aside for yourself.”
Blue Cross said Methodist’s latest offer “fails to deliver savings that will immediately support affordable coverage.”
“Methodist Le Bonheur Healthcare charges us much higher rates than other Memphis-area facilities, which is ultimately unfair to our members. We simply ask Methodist to accept fair market rates in line with the broader Memphis market,” the insurance company said. .
Corinne S Kennedy covers economic development and health care for The Commercial Appeal. He can be reached by email at[email protected]
