Christie Clinic “believes” primary care doctors back in-network

CENTRAL ILLINOIS (WCIA) — Nearly 8,000 state retirees, concentrated in central Illinois, were sold a health insurance plan based on an inflated directory of doctors. In reality, Aetna Medicare customers in metro Champaign-Urbana actually had access to about half of the listed provider options, and patients in rural areas had little to no options.

It’s a story that’s becoming increasingly familiar in central Illinois: A corporate dispute between health insurer and healthcare institution ends in a breakup and patients losing affordable access to their longtime doctors.

Target 3 investigative reporters have received dozens of calls, emails and messages from retired educators who opted into Aetna Medicare during open enrollment in October without knowing the Carle Health facilities and doctors they use would no longer be covered by that plan as of January 1.

“I feel like Aetna knew in October during open enrollment. Some of this had to be in the works within, that there were going to be changes made,” said Vicki Good. She and her husband relocated to Champaign years after she retired from teaching in Paxton-Buckley-Loda in 2006.

Reporters first met Good in March after she got a letter from Aetna that said her primary care doctor at Christie Clinic would no longer be in-network on May 1 because of their relationship with Carle Foundation Hospital in Urbana.

“I had called several doctors to find out if I could get in, and they all were Christie doctors. And even though they were in my provider book, when I would call they would say, ‘Well, as of May 1, they’re going to be out of the network. So then I was left with Okay, who do I call?” Good explained.

But before she had the time to settle on a new provider, Good “got the letter that said my primary care physician was back in the network.”

She’s not alone. A couple of patients shared their letters from Aetna, so reporters asked Christie Clinic representatives for an update on what the clinic has described as a fluid situation.

“At this time, we believe Christie Clinic and Aetna have worked out an arrangement to keep all of the Christie Clinic providers and physicians in-network,” Anni McClellan, Christie Clinic’s Chief Financial Officer, said in a statement Wednesday.

Network status for “less than 30” specialists “continues to be evaluated.” The number of doctors affected by Carle Foundation Hospital’s split with Aetna Medicare has grown from the “less than 17” figure McClellan provided on March 23.

Patients should be receiving updated notices in the mail from Aetna, if they haven’t already, McClellan said.

“Physical therapists, audiologists, and ancillary services (i.e. imaging, lab, cardiac diagnostics) remain in-network for Aetna Medicare Advantage. Patients should contact Aetna directly for its official coverage position with respect to any provider.”

The update was welcome news to Aetna patients in Champaign-Urbana because Christie Clinic doctors make up two-thirds of the primary care physicians available to them, according to a directory mailed to Vicki Good upon request at the end of March.

Target 3 reporters called through the entire list of 168 doctors and found out it was riddled with errors.

About half of the options advertised to Champaign-Urbana patients weren’t real. A few of them were actually specialists, like oncologists or cardiologists, others weren’t taking new patients at all.

One doctor on the list led reporters to a vacated office space off of University Avenue in Champaign, now available for rent. A receptionist at the dentist’s office next door said he retired.

“If something happens and I’m very ill, I’m not going to have the time, or the energy, or whatever it is that you need to make these phone calls and be told one thing, and then be told another thing, and that sort of thing,” Good said.

“And I don’t understand why Aetna is doing this to, you know, long-term customers.”

Of the 168 primary doctors that Aetna said it covers statewide, 39 are within ten miles of Good. 18 of those are real options, that’s assuming all Christie Clinic doctors remain in-network. Without Christie doctors, the number of available physicians shrinks to six for the Champaign-Urbana metro.

Federal network adequacy law requires insurers to offer a certain number of doctors (1.67 for every 1,000 patients on the plan) to be within a ten-mile drive for patients in metro areas. 559 retirees living in Champaign County are enrolled in Aetna Medicare through the Illinois Department of Central Management Services (CMS), the state agency that administers Medicare plans for state retirees. By that number, Aetna’s network of 18 doctors would be adequate under federal law, but it may not be a complete number.

Aetna has refused to release the number of patients on its plan, making that determination difficult to impossible.

Two Carle Health doctors were listed in the print directory, both far beyond 10 miles of Good in Richland and McLean Counties. Carle representatives would not address how many doctors fell out of network this year when reporters posed the question in March.

Carle Health Public Relations Manager Brittany Simon only said the Urbana hospital was no longer in-network when reporters first started digging in mid-March, but that doesn’t appear to be the case according to multiple patients.

Mike Rodebaugh is Aetna Medicare patient in Toledo, Illinois. The 65-year-old retired from Eastern Illinois University after a 23-year career. He says his insurance agent recommended he opt into the Aetna insurance plan following his 65th birthday last year, because “that would give me the most good, less out of pocket,” he said.

“I told him I needed something that Carle takes for sure,” Rodebaugh continued.

He said he’s been seeing his primary care doctor at a Carle clinic in Mattoon for more than a decade. In all, Rodebaugh was a Carle Health patient for more than 30 years before discovering in late March that his doctor and the Mattoon walk-in clinic he frequented were out of network.

Rodebaugh said he received no notice of the loss of coverage for his doctor’s appointments. He sat through two doctor appointments, one on March 18 and one on March 23, before he knew any better.

“The receptionist never said anything,” he said.

“I went in and seen the patient accounts girl. And we talked and she said, ‘Could I see your [insurance] card?’ And I said, ‘sure.’ And as soon as she looked at it, she said, ‘Oh gosh.’ She said, ‘You’ve already seen the doctor and stuff?’ I said, ‘Yeah, got right in.’ ‘Here’s the trouble,’ and she told me it was my Medicare card and said that Carle does not take Aetna [Medicare] insurance anymore,” Rodebaugh explained.

That was the first notice Rodebaugh got, seemingly three months after his doctor and clinics fell out of network. He says he gets other notices in the mail from his insurer on a monthly basis.

“How many people have got the same trouble I have right now that don’t even know it?”

The bill came in the mail this week. Rodebaugh says the out-of-network rate for his annual check-up and blood work was $435. He says an account services representative at the Carle clinic told him they may be able to cover the cost considering the circumstances. 

Reporters asked Simon, Carle’s public relations manager, directly: “Does Carle intend to cover Mike Rodebaugh’s 3/18 and 3/23/22 bills, considering he went through his appointments without knowing, or ever receiving notice, that he was out of network?”

Here’s the response:

Carle works with any patient to address billing concerns or if they’re struggling to pay a bill. Patients with billing questions should call directly to 888-71-CARLE to identify opportunities for adjustments, payment plans or for charity care.

In an earlier statement Thursday, Simon said, “Aetna’s previous Medicare Advantage HMO and PPO contract did not include access to the Carle Physician Group, including Carle Mattoon clinics,” contradicting Rodebaugh’s experience. He said he and his insurer specifically chose the plan in October based on it including the Carle doctor he’s been seeing for 10-15 years in Mattoon. He said he verified this again in a more recent Aetna provider directory after the first of the year.

A quick search of Carle’s “Health Plans Accepted” webpage shows Aetna Medicare plans are no longer accepted at facilities within 100 miles of Rodebaugh. The covered facilities remaining are Carle BroMenn Medical Center in Normal, Carle Eureka Hospital near Peoria, and Carle West Physician Group, which appears to be based out of Bloomington.

So, what are Rodebaugh’s options without Carle? None within 30 miles, according to Aetna’s statewide directory of doctors that Good received in March. 30 miles is the maximum distance a patient in a rural county has to drive to a primary care provider, according to federal regulations.

“Doctors aren’t very plentiful around this area that I live in,” Rodebaugh said.

As for who should have notified Rodebaugh of the change to his coverage, CMS says that’s the insurer’s responsibility.

Cathy Kwiatkowski, CMS’s deputy director of communications said insurance companies must make a “good faith effort” to notify patients at least 30 days before breaking up with their doctor.

Read her full response:

The Illinois Department of Central Management Services (CMS) administers the healthcare plans that are available to State retirees who are enrolled in Medicare in accordance with all federal guidelines. Pursuant to 42 CFR §422.111(e), when a plan makes changes to its provider network, the plan must make a good faith effort to provide written notice of a termination of a contracted provider at least 30 calendar days before the termination effective date to all enrollees who are patients seen on a regular basis by the provider whose contract is terminating. When a contract termination involves a primary care professional, all enrollees who are patients of that primary care professional must be notified.

As this is a fully insured MAPD plan for eligible enrollees, CMS does not track which providers are utilized by an enrollee, therefore would not be in a position to issue notification.

Aetna claims the company notified “members who utilized Carle Hospital providers in Champaign and Hoopeston within the prior six months” in September. Rebecca Ferrick, representing Aetna’s parent company CVS Health, would not address why patients affected beyond Champaign and Hoopeston, like Rodebaugh, weren’t notified.

Rodebaugh called CMS after losing in-network access to his doctor to try to change his insurance.

“And she says, ‘Yes, you need to either change doctors or on October 1 of this year, you can select a different insurance.’ I said, ‘Now, wait a minute, you guys are supposed to have insurance for me,'” Rodebaugh said.

If he does make the switch in October, the plan new plan wouldn’t take effect until January 2023.

“Right now I’ve got nothing. And the state of Illinois is supposed to give it to us, as far as I know, because you don’t work someplace 23 years just for the fun of it usually,” Rodebaugh said.

“The very least they can do is be more open and transparent with what’s going on,” Good said of her insurer.

State retirees in 47 counties rely on Aetna Medicare as one of two options for health insurance.

“Aetna is definitely the lesser expensive between it and United Healthcare,” Good said, explaining why she chose her insurer.

A portion of her retirement is subtracted each month to pay for that chosen plan, a plan that is not as advertised.

In more than half of those 47 counties (at least 25), Aetna doesn’t have a single primary care doctor available to see seniors, according to the print directory Good was mailed.

State law requires one primary care provider per county. However, Medicare plans are regulated by federal law which doesn’t include the same provision.

I asked Good what she plans to do come open enrollment in October.

“You know, I’ve given a lot of thought to that. And with all that’s gone on with Aetna, I may want to look into the United Healthcare and just see how much more expensive and all that might be,” she said.

“But then I would not have to worry about somebody going in and out of network.”

Since we interviewed Rodebaugh, he was able to make an appointment with a doctor this week. The new provider is about 20 miles away at a Sarah Bush Lincoln clinic in Neoga. She wasn’t in the directory prior.

“But I just, I don’t want to switch. I’ve had such good luck there for, like I say, over 20-25 years,” Rodebaugh said.

“It makes me want to wonder why it’s just happening to the people 65 and older, older. It doesn’t seem right.”

CMS conducts network adequacy reviews for the plans it administers on a quarterly basis, according to Kwiatkowski, who prefaced the statement with, “CMS relies on [the Federal Centers for Medicare & Medicaid Services] to ensure that the plan is in compliance.”

“To date, CMS has received no notification from the regulatory entity regarding a change in provider network adequacy for this plan,” she said in an email statement Thursday evening.

Although, the network of primary care doctors for Rodebaugh and at least 68 other patients enrolled in Aetna Medicare in Cumberland County, was in apparent violation of federal law for a period of time.

Ferrick claimed Aetna is “confident [its] network of health care providers can meet the needs of members impacted by this change,” adding, “Aetna members can contact Member Services if they have questions.”

The media representative said the company would “welcome the return of Carle Hospital and Carle providers in Champaign and Hoopeston into our Medicare Advantage network.”

Reporters asked CMS if they’re considering solutions, including offering other HMO options for state retirees to opt into.

Here’s the email response from Kwiatkowski:

ICMS regularly issues Request for Proposal for MAPD plans, in accordance with State of Illinois procurement rules, incorporating industry best practices and latest trends to provide best value for the members.

If you are a state retiree or rely on an Aetna Medicare plan for affordable healthcare, we want to hear from you: