SPRINGFIELD, Ill. (WCIA)– Cancer patients caught in the middle of a corporate contract dispute watch as their medical bills soar.
They’re a sub-group of tens of thousands of patients who lost affordable access to their familiar healthcare providers on Nov. 17, the date when Springfield Clinic’s roughly 650 doctors and nurse practitioners fell out-of-network for patients with Blue Cross Blue Shield.
The months-long contract dispute between Illinois’s largest health insurance provider and Springfield Clinic does not appear to have an end in sight. Meanwhile, urban and rural patients alike, spanning 20 counties in the central part of the state, are forced to choose between paying more to see the providers they trust and navigating an online directory to find a new doctor.
BCBS estimated 55,000 of its members were affected by the change, according to a senior communications representative. Springfield Clinic claims the fallout affected 100,000 patients.
Gail Courtney is one of those patients. The 57-year-old breast cancer patient in Franklin, IL, has counted on her Springfield Clinic doctor in Jacksonville since her diagnosis in the fall.
Courtney described the cancer as aggressive, requiring a mastectomy and six subsequent rounds of chemotherapy. She squeezed one of the six treatments in before her doctor fell out of the BCSC network.
“Nov. 6 was my first one,” Courtney recalled. “And it shows that the clinic billed for $20,000 and that I owed nothing.”
She pulled out a second bill.
“And then here’s another one,” she said. “This is the Neulasta shot, I believe the day after. It’s $10,890 and I owe nothing. All of these are from my first chemo, you know, my doctor visit and it shows that I owe nothing.”
Courtney said she was able to cover her deductible and her health insurance provider, BCBS, picked up the rest.
But two weeks after the first round of chemotherapy, her doctor was no longer covered as “in-network.” Following a life-changing diagnosis, she recounted that as the moment it all changed.
“Because all of my chemos would have been covered,” Courtney shared.
So, why not switch doctors?
“Because I trust my doctor,” Courtney responded confidently. “I mean, I have an oncologist that I trust at Springfield Clinic and I trust him with my life. I don’t want to have to switch to somebody I don’t even know.”
She briefly perused other options in the Blue Cross Blue Shield network, but felt those doctors were too far away, especially for the return trip after the exhausting bout with chemo. According to her, the next best in-network option for an oncologist was about 80 miles away near St. Louis.
State insurance law, under the Network Adequacy and Transparency Act of 2017, requires companies to cover certain patients for a 90-day transitional period after an established doctor leaves their health insurance network. Those in the industry call this “continuity of care.”
The Illinois statute defines “ongoing course of treatment” as an option available for patients with a “life-threatening condition” or a “serious acute condition,” specifically including “chemotherapy, radiation therapy, or post-operative visits”, among other specific instances.
READ THE FULL DEFINITION under 215 ILCS 124:
“‘Ongoing course of treatment’ means (1) treatment for a life-threatening condition, which is a disease or condition for which likelihood of death is probable unless the course of the disease or condition is interrupted; (2) treatment for a serious acute condition, defined as a disease or condition requiring complex ongoing care that the covered person is currently receiving, such as chemotherapy, radiation therapy, or post-operative visits; (3) a course of treatment for a health condition that a treating provider attests that discontinuing care by that provider would worsen the condition or interfere with anticipated outcomes; or (4) the third trimester of pregnancy through the post-partum period.”
To Courtney, “That meant that it would continue to cover my Springfield Clinic doctor at an in-network rate. Instead, I owe all of this money.”
“For those members with benefit plans covered by Illinois state law, it’s actually defined by statute,” BCBS said in a statement when asked how the company defines “continuity of care”.
“For example, members being treated for a disability, acute condition, life-threatening illness, or in the third trimester of pregnancy at the time of termination may be covered by what is known as ‘continuity of care.’ This means the member may still be able to use Springfield Clinic providers at the in-network benefit level under their plan.“
Springfield Clinic’s take on continuity of care was that it “should” be available.
The full statement from a representative said the healthcare organization “continues to advocate for and provide care for patients that were impacted by BCBSIL’s termination of the PPO agreement,” adding, “We believe that the most impacted patients who have received continuity of care should be able to continue that care as in-network.”
When Courtney’s bills skyrocketed after mid-November, a complaint was sent to the state Department of Insurance. State officials claimed her self-insured health plan does not fall under state regulation, and instead, is the responsibility of the federal government to regulate through the U.S. Department of Labor.
According to documents obtained by the Target 3 team, BCBS said the complaint on Courtney’s behalf “should not be considered a ‘valid complaint.'”
Federal law also holds health insurance companies to a 90-day standard under the No Surprises Act, last updated in January.
And while the back-and-forth has continued over which government agency is responsible for addressing the insurance complaint, the money owed is piling up for the cancer patient.
So far, Courtney has received an Explanation of Benefits (EOB) — a statement from the health insurance plan that breaks down what costs it will cover — for three out of five rounds of chemotherapy she’s undergone to date.
The first EOB, dated Nov. 8, was covered in full, according to Courtney. That was before her doctor fell out of BCBS’s network.
Add up the out-of-network EOBs for the two subsequent treatments in late November and December and it shows she owes $47,182.29.
Not to mention, the cancer patient has yet to lay eyes on what’s owed for the remaining two treatments and another coming up next week.
We asked Courtney, “Are you going to be able to afford all of that?”
“No,” she laughed. “I mean, they’re going to drive people into bankruptcy is what they’re going to do,” Courtney continued.
“They need to quit passing this on to the patients. I mean, if you have continuation of care, it should cover this, like it did previously.”
A representative with the state Dept. of Insurance expressed disappointment in the unresolved conflict between BCBS and Springfield Clinic, claiming it led “to the detriment and confusion of consumers.”
“We are aware that some Springfield Clinic consumers have made complaints about charges for clinic providers deemed out-of-network by Blue Cross Blue Shield,” an email statement continued.
“Our goal has always been to reach an agreement with Springfield Clinic that is in the best interests of our members and group customers,” a BSBC representative relayed in an email when asked why a deal hasn’t been reached.
“Springfield Clinic hasn’t yet indicated a willingness to discuss an agreement that focuses on the improved health outcomes and more affordable care our members expect, but we’re always open to resuming those discussions, and have made specific outreach to Springfield Clinic Leadership and their Board of Directors over the past many months.”
Springfield Clinic provided a statement Wednesday to the contrary.
A representative said, “Any suggestion that Springfield Clinic has not negotiated in good faith is untrue. We made a proposal in August but based on BCBSIL’s communication to us, we do not anticipate an agreement.”
The clinic shared this sentiment as early as Aug. 9 in a letter to affected patients, specifically stating, “We do not anticipate a resolution with BCBSIL.”
“You should be dealing with getting better and trying to live, not have to fight your insurance company, and that’s what we’re doing,” Courtney said, adding she’d much rather switch her insurance provider and keep her doctor.
But she told us that’s out of her control.
“People can’t just change insurances because you get it through where you work, and you’re stuck,” she continued.
“They’re taking people’s money for the premiums, but they’re not paying what you expect them to pay.”
The 57-year-old said she pays around $500 a month for health insurance, a cost deducted before she receives her paychecks. Those don’t go as far as they used to, she said.
“Nobody can pay this kind of…” she trailed off.
Courtney worries that by the time her cancer treatments are over, the money owed is “going to be astronomical.”
She fears, in the end, she may have to spend her life savings in order to save her life.
“I have to have the chemo so I’ve continued to do it, and I’ll just, you know, owe for the rest of my life, I guess,” she concluded, wondering how many others might be fighting the same battle.
“I feel like I’m all alone here. I mean, I feel like it’s just me, but I know it’s not,” Courtney said, describing an isolating feeling during a most uncertain, terrifying part of her life.
Self-funded plans, like Courtney’s, are common among large employers. According to the Illinois Dept. of Insurance (DOI), the U.S. Dept. of Labor has the regulatory authority over these plans. That’s where the state department suggested those with self-funded plans turn for complaints, appeals and other assistance.
Fully-funded plans are regulated by state law. If there’s reason to believe that a health insurer is not honoring policy terms on those plans, the DOI said complaints can be filed online or by submitting this form.