SPRINGFIELD, Ill. (WCIA) — Envelopes detailing thousands in healthcare expenses owed immediately continue to arrive on Jim and Sharon Whaley’s doorstep.
The couple is feeling the weight of a corporate dispute between their health insurer — Blue Cross Blue Shield of Illinois — and Springfield Clinic, which has become the sole supplier of several healthcare specialists in-and-around the capital city.
Jim Whaley is a Springfield electrician. He’s spent around 40 years working on “traffic lights, highway lighting, stuff like interstates.” Much of what he does is “a little bit high voltage.”
It’s about the same amount of time he’s been married to his wife and partner in sickness and in health, Sharon Whaley. We met the pair at their home in Springfield, where they sat hand-in-hand, sharing laughter and tears.
Whaley joined the International Brotherhood of Electrical Workers, IBEW Local 51, about 20 years ago for the family he built with Sharon. In 2001, the father of three left another gig as an electrician with a small business for access to health insurance that would cover the cost of his daughter’s insulin. At the time the Whaleys said that was running them $800/month. Joining IBEW and subsequently, Blue Cross Blue Shield of Illinois slashed the cost to $50/month.
20 years and a cancer diagnosis later, the Whaleys worry their kids now may have to pick up some of the cost of Jim’s ever-growing medical expenses coming in from Blue Cross Blue Shield of Illinois.
“You thought you did everything right,” Sharon said. “You bought the best insurance that was out there. We took the highest, you know, level we could get. We got the okays.”
Doctors diagnosed him with Squamous cell carcinoma, a type of oral cavity cancer or more simply “cancer of the mouth” as Jim described. The treatment was not so simple. Surgeons “removed his jaw and all of the gum lining there, they dissected his neck, removed all his lymph nodes,” Sharon described as Jim rolled up his pants to show where “they went and took his fibula out of his left leg and made a new jaw bone out of it.” After that, months of radiation therapy.
“I stayed on the job as long as I could, until basically the doctors told me I needed to quit,” he told us.
The news unraveled in September, the couple said. Whaley stopped working on November 12 and his surgery was scheduled for November 17, the day BCBSIL knocked the family’s Springfield Clinic doctors out of network affecting an estimated 100,000 patients.
“There is no other radiation therapist other than at the clinic who’s out of network, so I think it was like December 6, [Jim’s Springfield Clinic doctor] applied and talked to Blue Cross…and started the paperwork and stuff to get us okayed through blue cross.”
They waited three weeks for the okay from their health insurer, any longer Whaley said would have risked the cancer spreading.
“I had to get the radiation case the cell got loose,” he explained.
Then the mail came. In it, an Explanation of Benefits (EOB) from BCBSIL, expecting $50,000 immediately, Sharon Whaley told us. The family said Monday they’ve yet to see the total price including treatments in the last couple of months.
“I mean, you pay your premiums, you do what you’re supposed to,” Sharon said with emotion building up behind her voice.
The future weighs heavily on their home with questions of whether they’ll afford future vacations, if retirement is still an option, “and then have your kids say, ‘We’ll do whatever so you don’t lose everything,'” Sharon shared.
“Heartbreaking,” she said holding back tears. “But we made it, we want to keep going.”
The Whaleys said Springfield Clinic filed an appeal over the cost of Jim’s radiation treatments with the state.
A PR firm now handling communications for Blue Cross said in a statement Monday afternoon the company has approved more than 1,400 continuity of care requests since kicking Springfield Clinic’s around 650 doctors out of network, some of those for members undergoing cancer treatments.
The state’s Network Adequacy and Transparency Act of 2017 requires insurance companies to continue to cover the cost of acute care like cancer treatment at the in-network rate patients were paying ahead of those providers falling out of network.
To date, the Whaleys say they have gotten just a verbal confirmation of that continuity of care over the phone from BCBSIL representatives, but the EOBs don’t match that promise.
151 complaints have been filed with the state Department of insurance against Blue Cross Blue Shield of Illinois following the separation from Springfield Clinic. Most of those were reported in November.
The Whaleys have what’s known as an ERISA (or group-funded) health insurance plan which is regulated by the U.S. Department of Labor. Federal law spells out similar continuity of care requirements.
Rep. Thaddeus Jones (D-Calumet City) recently penned a bill to require insurance companies to print on back of insurance card whether their plans are regulated by the state Department of Insurance or the U.S. Department of Labor.
The Dept. of Insurance fined BCBSIL’s parent company (Health Care Service Corporation) $339,000 Friday “for violating the material change notice requirement in the state’s Network Adequacy and Transparency Act.”
In a press release Monday, the DOI said “the company did not properly file updated network adequacy filings following the termination of its contract with Springfield Clinic which serves approximately 100,000 consumers in Central Illinois.”
A hearing is set for the House Insurance Committee Tuesday where state lawmakers plan to dig into Blue Cross Blue Shield of Illinois’ handling of its negotiations with Springfield Clinic.