A year later, state still reviewing ‘ghost network’; Rules to tighten insurance regulations pending

SPRINGFIELD, Ill. (WCIA) — A year after Blue Cross Blue Shield of Illinois (BCBSIL) kicked Springfield Clinic, along with its 450 doctors and 200 advanced practice nurses, out of network, a top executive revealed that the clinic is “not optimistic about an agreement.”

In response to an update request from WCIA 3 Thursday, Chief Financial Officer Chase Hammon said Springfield Clinic is “disappointed” that efforts to restore a previously decades-long relationship with the largest insurer in Illinois “have not been more fruitful.”

“Springfield Clinic has been diligently working to find a compromise with Blue Cross Blue Shield,” Hammon said in the opening line of his statement.

“It does not appear that the Clinic is interested in reaching an agreement,” a BCBSIL media contact said following the same request for an update.

The mutual legal reserve company claimed it has proposed “an arrangement to the Clinic that would deliver quality and value for our customers,” the email response read.

Committee hearings at the State Capitol in March revealed there has been “back and forth” and BCBSIL representatives admitted Springfield Clinic has been somewhat flexible in rate negotiations. Although, to date, neither side has shared documentation.

Meanwhile, open enrollment is underway for tens of thousands of patients — BCBSIL executives say 55,000 and Springfield Clinic doctors say 110,000 — affected by the breakup between their insurer and provider in November of 2021.

“We have to make those decisions, and here we are in limbo,” Springfield Clinic oncology patient Debbie Ackerman said just ahead of the companies’ revealing an apparent stalemate Thursday.

Negotiations have not stopped at this point.

“If they were going to have an agreement, wouldn’t you think they would have done so by now, knowing that this is the renewal time for so many people?” Ackerman said.

BCBSIL patient options were depleted without Springfield Clinic, so much so that the Illinois Department of Insurance fined the insurance company $339,000 in March for failing to report to the department a “material change.”

The Network Adequacy and Transparency Act of 2017 requires insurers to maintain a “minimum ratio of providers,” and to report a “material change” to the Illinois Department of Insurance if it significantly reduces the number of providers in its network. 

The first-ever fine of its kind was announced two weeks after Target 3 first exposed dead ends in the BCBSIL’s directory of doctors.

The fine did not address the most direct stressor for patients who continue to face higher costs, extended wait times, longer drives, and who, a year later, continue to have to navigate a provider list riddled with errors.

In early March, reporters found the company’s in-network list for a number of specialties, including obstetricians and radiation oncologists, were diminished to the point of an apparent state law violation.

For example, the law requires at least three radiation oncologists within 60 miles of Springfield based on BCBSIL’s more conservative number of patients enrolled in its health plan in the capital city, and they have to be available within two weeks of a patient calling to schedule an appointment.

A scan of the network Thursday, eight months after our initial investigation, showed just one radiation oncologist — albeit a doctor added in the last couple of months — who fit the aforementioned criteria. That one doctor is more than 30 miles outside of the capital city.

Ackerman, who lives in Lincoln, Illinois, started seeing two Springfield Clinic oncologists (one medical and one radiation) a year ago. Within a month of beginning treatment, they were kicked out of her BCBSIL network.

After fears of delayed treatment, she was finally approved to keep seeing them at the in-network rate until the end of the year when her employer switched insurance plans.

Since then, her place of employment has closed and this month, she said she will have to enroll as a dependent on her husband’s insurance: BCBSIL.

Ackerman said she still sees an oncologist every three months and doesn’t want to switch now if one is even available to see her.

“That doctor comes to Lincoln once a week, and so my follow-up appointments are here in Lincoln,” she shared.

She was also able to complete her chemotherapy treatment with the radiation oncologist from Nov. 2021 through April in the small town where she lived.

“Which was incredible, not having to make that commute and go to the expensive, you know, back and forth to Springfield for treatments,” she added.

“That was critical for us.”

With the provider network remaining largely unchanged, a switch to BCBSIL would likely involve traveling at least 45 minutes from home. Ackerman scanned the private insurance marketplace and said there isn’t another viable choice.

“The difference between jumping on my husband’s and what’s available to me on the marketplace, it’s significantly different, and it’s significantly more expensive through marketplace to the extent that that’s not an option for us,” she said.

Ackerman has until early December to make a final decision.

Following our initial investigation in March, the Illinois Department of Insurance entered its own investigation of BCBSIL’s provider network.

The network adequacy filing from BCBSIL remained under review Thursday, according to director of communications Caron Brookens.

“…the Department does not comment on filings that are under review. When the Department’s review is complete, we will provide an update,” Brookens responded to a Target 3 request for an update.

This means patients will likely have to enroll in a health plan for the next year without added knowledge expected to come eventually in the results of a months-long investigation.

Depending on those results, additional penalties against the insurance company could be in store.

Sen. Doris Turner (D-Springfield) penned a letter to Gov. J.B. Pritzker’s office Wednesday calling on the executive branch to “use its statutory authority to defend people’s right to accessible and affordable care.”

“I implore the Illinois Department of Insurance to take quick action regarding BCBSIL’s provider directory and failure to meet network adequacy regulations or prohibit the company from selling inadequate plans for the 2023 plan year,” the letter read.

The senator, who is the democratic incumbent in a tightly contested race with Rep. Sandy Hamilton (R-Springfield), said she is still hearing from affected families a year later “that matters are getting worse.”

“This has gone on long enough,” Turner said. “Residents should not have to compromise their health.”

“We appreciate Senator Turner’s attention to this matter,” Brookens included in the email response from the Illinois Department of Insurance. “We take seriously our regulatory authority of health issuers offering plans on and off the ACA Health Insurance Marketplace, and if a provider network is found to be inadequate, the Department will take the appropriate steps.”

Rep. Hamilton was a vocal member of the group of lawmakers who heard testimony from BCBSIL executives and Springfield Clinic doctors at the end of March.

“We’re not a part of the negotiation process, nor do we want to be, but I felt like it was 100% a step forward,” she said in an interview with Target 3 the day after the hearing of the House State Government Administration Committee. “We needed to do something, not that we needed to get involved, but we needed to do something.”

Her office did not return request for comment Thursday.

Also the day after the hearing (April 1), the Illinois Department of Insurance proposed a new set of regulations that would more strictly enforce current network adequacy laws and improve transparency for patients. 

In sum, the rules would require insurance companies to disclose more regular, accurate information detailing distance and drive times between patients and their available medical providers. The data, which is currently considered confidential, would help state regulators and the public quickly analyze how many doctors or specialists are available to see them in their area. 

Insurers would also have an annual obligation to file their provider directories for every plan they sell patients, specifying when those specialists are only available for virtual visits.

The 14-page document is pending adoption by the Joint Committee on Administrative Rules (JCAR). All but one of the proposed rules would go into effect immediately upon passage.

“Although I’m on the other side of my treatment now, there are so many people that aren’t and really struggling,” Ackerman said before hanging up with Target 3 reporters Thursday.

“When you’re going through treatment, you need to focus all of your energies on that, and not have to figure out whether your treatment is going to be postponed or covered or out of network at a greater expense.”