SPRINGFIELD, Ill. (NEXSTAR) — Cancer patients, pregnant mothers, and other patients in dire search of medical attention face higher costs, longer wait times, farther distances, and have to navigate a dead-end directory of doctors that, in many cases, do not exist before they can schedule their first appointment with a specialist in the Blue Cross Blue Shield network.
Experts in the insurance industry often refer to an insurance company’s inflated patient directory as a “ghost network” that over-promises and under-delivers on the number of providers who are actually available to see patients within a reasonable distance.
A spokesperson for Blue Cross Blue Shield of Illinois said the “assertion of a ghost network is inaccurate and may be based on misplaced assumptions,” but a thorough review of the company’s directory, including hours of phone calls placed to the providers offices, yielded pages of evidence that the doctors they advertise are often not available, not taking new patients, located too far away, or in some cases don’t work there at all.
Online directories often include an occasional error or oversight, but in this case, the complications in coverage grew drastically worse after the largest insurance company in Illinois escalated a contract dispute with Springfield Clinic and kicked all 650 of its providers “out-of-network” in mid-November.
Several mothers who get their health insurance through Blue Cross Blue Shield described the hardball negotiations as a big city boardroom decision that carries real-world impact for their family and strains their relationship with their favorite doctor.
Morgan Kaplan is a young mother from Springfield who opted to pay higher out-of-pocket costs to keep her doctor at Springfield Clinic instead of taking her chances with another provider in the Blue Cross network.
“It just sounds like it’s some big wigs sitting in a big office in Chicago and just calling the shots,” Kaplan said about the contract dispute. “They’re just like the 800-pound gorilla, and I think some of these smaller towns and their smaller physician practices, they’re not able to come up against an 800-pound gorilla.”
Our Target 3 investigation revealed a pattern of glaring instances where patients with Blue Cross Blue Shield of Illinois health insurance plans were not receiving the protections promised under state and federal law.
Continuity of Care
Gail Courtney just recently finished up her sixth and final round of chemotherapy. State laws include protections that are supposed to prevent her from disruptions in coverage during her chemo and radiation treatments. Despite those promises in the law, the 57-year-old breast cancer patient in Franklin, Illinois, says she’s facing ‘astronomical’ medical bills. She was diagnosed in the fall and her first round of chemotherapy was covered by her insurance.
Her Springfield Clinic oncologist fell out of network with her health insurer, Blue Cross Blue Shield, before she got to her second round. That’s when her bills started to soar, totaling $46,000 after the first three rounds of chemo.
“They’re gonna drive people into bankruptcy is what they’re gonna do,” Courtney said.
“I mean, I have to have the chemo. So I’ve continued to do it,” she said. “And I’ll just, you know, owe for the rest of my life, I guess.”
After our first report revealed her elevated costs, Blue Cross said it would start “re-reviewing the claims for all members receiving continuity of care at Springfield Clinic. If any errors occurred, we will make it right.”
Impacts from the ongoing contract dispute between clinic and health insurer stretch far beyond Courtney’s story alone. Bills, stress, and frustration have swelled for patients spanning 20 counties in Central Illinois.
Expecting mothers bore the brunt of the fallout, and the stress that comes with it. Several pregnant mothers were in their third trimesters when they suddenly lost the guarantee that the health insurance coverage benefits they paid for and relied on would last all the way through their post-partum care.
Those mothers who opted to switch in a hurry ran into challenges trying to find a new provider.
“It’s kind of a time-sensitive issue,” Elizabeth Farris Byerline said.
Farris Byerline was about five months pregnant when her obstetrician fell out of network. She was one of tens of thousands of patients whose Springfield Clinic doctors haven’t been covered by their health insurance since mid-November.
“I called like, I feel like 100 times a day,” she added, referring to calls made to her insurance provider, Blue Cross Blue Shield. In the meantime, her worries continued to grow right alongside with her baby.
When she did reach someone on the other end of the line, “What [BCBS] said is they’ll consider my provider an in-network provider until the end of May,” Farris Byerline said.
Her “continuity of care” was verbally approved by insurance, but her doctor is still waiting to get that promise in writing, and she claimed a BCBS customer service representative said her covered visits could be limited.
After a food poisoning incident, doctors considered her pregnancy “high-risk,” though she worries her insurance benefits may not cover all of the extra visits.
“Every single time I go into an appointment at Springfield Clinic, I have to sign a form that says, you know, we’re still waiting for the continuity,” Farris Byerline explained. “However, if, for some reason, it doesn’t go through, I’m responsible for any of the accrued expenses.”
She estimated her family has piled up close to $20,000 in medical expenses as she awaits her baby, the gender of whom is unknown because unlike her bill, Farris Byerline and her husband want that to be a surprise.
When asked about how a $20,000 bill might affect her growing family, she said, “It would probably be pretty crippling.”
Blue Cross Blue Shield declined an interview. So Target 3 investigators pressed them in an email: “Can you guarantee that every pregnant mother granted continuity of care with a Springfield Clinic OB will not pay a dime more than they would have at another in-network provider?“
In an email response, Blue Cross Blue Shield tried to shift the blame for the uncertainty on to Springfield Clinic but ultimately acknowledged, “We cannot guarantee that.”
Not too far from the Byerline household, another Springfield mother, Amanda Lawler, had yet to see documentation to prove she has the ‘continuity of care’ that she said her insurer, BCBS, also promised her. Lawler is expecting her second child at the end of the month.
She, too, has yet to see a final bill; but that’s not abnormal, according to a representative with Springfield Clinic. Bills generally arrive after the baby is born, which is another source of uncertainty and added stress for Lawler and a slew of other expecting mothers caught up in the contract dispute.
Once the bill arrives and postpartum care is complete, any ‘continuity of care’ protections will run out, and their out-of-network expenses would start to kick in. Lawler said she will have to begin the search for a new OB/GYN at that point.
“The way that medical bills are charged, there’s no way I could pay out of pocket,” she shared.
That said, Lawler, Farris Byerline and others we interviewed for this report are seeing an alarming preview of what it will take to move on to a new provider. They described waiting rooms filling up at the one other healthcare facility offering OB/GYN care in Springfield: SIU Medicine Obstetrics & Gynecology.
“I’ve seen a lot of struggle,” Lawler continued. “A lot of either people just saying, ‘Okay. Well, I won’t have a doctor, I’ll run into prompt care when I need it.’”
“I had other friends who weren’t as far in their pregnancies who had to kind of look for providers at SIU, and their waiting list, I mean, obviously they had all of these patients flood over to them,” Farris Byerline added.
“If you can even get onto a waiting list,” Lawler quipped.
The mothers-to-be have also noticed fewer women walk into Springfield Clinic as they wait for their doctors.
“They were always busy and now you see, when I go in the waiting rooms [they] are so much less. I mean, I would say 20% of the people are there,” Lawler said of what she’s noticed since the split between BCBS and the clinic in November.
Kaplan, the young mother from Springfield, unsuccessfully pleaded with her employer to switch insurance plans and ditch Blue Cross. She was not surprised to see other waiting rooms start to fill up and overflow as more patients start avoiding the higher out-of-pocket costs at Springfield Clinic.
“I think it just comes down to like basic math, right?” she said.
Kaplan, also insured by Blue Cross, has not made the switch to another provider. She said she’s putting off her annual check-up, hoping the clinic and her health insurer resolve their dispute in time. She chose to pay the higher costs out of pocket instead of trying to find a new provider. The two companies remain deadlocked as of this report.
“Springfield Clinic is probably one of the biggest clinics here in town, if not the biggest,” Lawler said. “And Blue Cross Blue Shield, I feel like everybody that works for a big company or something has that.”
In calling through the BCBS online directory of obstetricians in the area for ourselves, we found out that the soonest someone could get in to see a doctor in Springfield is at least two months out. Getting in to see a female doctor required a six month wait, according to receptionists and schedulers with local healthcare providers.
The soonest an expecting mother could get in to see a doctor within 30 miles of the capital city was two weeks, but that would require an about 40 minute drive to Jacksonville, IL.
Patients who decide to drop their Springfield Clinic doctor for a new provider in the Blue Cross network have to navigate a labyrinth of headaches in the insurance company’s confounding online list that often leads them nowhere.
Blue Cross advertises one obstetrician, Doctor Eric Brown, as an in-network option who accepts patients at 2501 Chatham Road in Springfield. However, calls to one office number under Brown’s name get forwarded to a cleaning company in Michigan. Another number for Brown rings to his real office in Atlanta, Georgia, where he has practiced as a licensed obstetrician for years.
A receptionist in his Atlanta office said she sometimes gets calls from patients in Springfield, but she says he’s worked in Georgia “his whole life.”
Staff for Doctor Robert Kaufmann said he is a licensed allergist, and does not take OB/GYN patients.
The dead-end directory includes a myriad of other mistakes. Dozens of doctors Blue Cross advertises to its patients have already retired. Some receptionists don’t recognize the doctors’ names at all. Others listed on the website practice at Springfield Clinic, which means they’re no longer available at in-network prices.
At the bottom of the web page, a disclaimer warns Blue Cross Blue Shield customers they may have to foot the bill for any “uncovered charges” they incur from walking into a provider’s office on that list.
In a statement, a Blue Cross Blue Shield of Illinois spokesperson suggested doctors who left the network haven’t updated their information, and pointed to a new federal regulation that requires them to update or verify their directory details every 90 days.
“We rely on providers to update us about retirement and their ability to accept new patients,” spokeswoman Colleen Miller wrote. “Once we receive that information, we update our Provider Finder on a daily basis.”
Several hospital groups in Springfield have described difficulties in hiring adequate medical staff in the aftermath of the pandemic, but Miller claimed, “we continue to grow our networks as groups in our networks add to their rosters.”
The Backstory Behind Blue Cross Blue Shield’s Split with Springfield Clinic
Executives at Springfield Clinic say the dispute began when Blue Cross started steering a higher volume of patients onto a much cheaper insurance plan that was initially set up to provide barebones coverage for the previously uninsured.
“That plan was intended for the [Affordable Care Act],” Zach Kerker, a vice president at Springfield Clinic, explained. “It was intended for people who had purchased plans through the exchange online.”
The Blue Choice plan covered roughly 10,000 patients at Springfield Clinic, according to Kerker. When Blue Cross started selling that cheaper, lower-paying plan to a broader pool of patients, the clinic stopped accepting it.
“Ultimately, we canceled that plan, because there were other options for patients at that time to get their insurance through the exchange,” Kerker said.
The clinic’s executives didn’t expect Blue Cross Blue Shield to retaliate. When the state’s largest insurer escalated the dispute and kicked Springfield Clinic’s 650 providers out of its network, it told reporters it did so to start a broader discussion about affordable health care.
“That’s not what it felt like,” Kerker said flatly.
Both Springfield Clinic and Blue Cross Blue Shield of Illinois claim they want to reach a deal, but neither side has discussed specific rates in public.
“We cannot and will not arbitrarily overpay for access to care at the expense of our members and employer groups,” Miller said, referring to the pressures of inflation.
Documents reviewed by Target 3 show Blue Cross Blue Shield is systematically passing higher medical bills along to paying customers who continue seeking medical care at Springfield Clinic.
When doctors join an insurance network, they agree to “bulk discounts” to essentially provide specific procedures at a lower rate in exchange for access to a broader pool of patients. Depending on the patients’ coverage plan, the insurer determines how much of the rest of that bill it will cover, and passes the rest on to the patient. Now that Springfield Clinic doctors are out of the Blue Cross network, Blue Cross is essentially voiding that original “discount,” and forwarding the full brunt of the doctor’s expenses on to the patient. In other words, for patients who choose to stick with their Springfield Clinic doctor, it’s almost as if their insurance plan doesn’t exist.
“Our role is to adjudicate claims in accordance with a member’s benefit plan,” Miller explained. “While we would hope that Springfield Clinic would not balance bill the member for any amounts above what the member would have been responsible for when Springfield Clinic was in-network, we cannot guarantee that.”
While they declined to discuss details about the specific rates, Springfield Clinic doctors expressed concerns about the long-term impacts of inking a deal with Blue Cross that threatens their bottom line, and in turn, their ability to attract top medical talent to the region.
“What we get here in Springfield, Illinois, is equivalent to big city medicine, no doubt about that, except we still kind of retain some of that small town sort of vibe and small town feel, Springfield Clinic’s Chief Medical Officer Kenneth Sagins said.
“If you want to bring here the experts, you do have to make sure that folks are treated fairly and compensated fairly. And as rates continue to get ratcheted down for these [doctors], we feel that it’s less likely that they’ll come to this area to practice. And that hurts us all.”
‘Network adequacy’ laws promise protections for patients
Illinois state law requires insurance companies to provide an “adequate network” to its customers, and bars insurers from disrupting continuity of care coverage for cancer patients, pregnant mothers, or other patients in urgent need of life-saving care.
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 ratio includes requirements and patient protections to keep wait times and driving distances to a minimum. It also orders the insurance company to update its online provider directory once every month.
Different specialties include patient-doctor ratio requirements. For example, an adequate network must provide five neurologists, seven oncologists, 10 cardiologists, 20 general surgeons, 40 obstetricians, and 100 pediatricians or primary care doctors for every 100,000 members in the network.
By the conservative estimates Blue Cross provided, its pool of 55,000 affected patients would need a network with at least seven radiation oncologists and at least 22 obstetricians.
Its online directory advertises 10 radiation oncologists, but when Target 3 called each of their offices, only two were taking patients, and only one was available now.
The Blue Cross online directory also advertises 59 OB/GYN doctors, but only 12 of them listed are actually taking patients, and none of them are available now. Springfield Clinic’s 37 OB/GYN providers alone would satisfy the network adequacy requirements for that specialty, but they are no longer available at in-network rates for as long as the dispute continues.
“The Department of Insurance should have plenty of power to regulate this law,” House Majority Leader Greg Harris (D-Chicago) said in an interview. “But if, as you’re finding, there are entities who are finding their way around it, or are not complying, then clearly we need to do something stronger and tougher to get them into compliance.”
The law requires the company to “report the change within 15 days after the change occurs.” Despite the significant reduction in providers on its network, Blue Cross had not notified the state about the changes for more than 100 days, an apparent violation of the law.
After Target 3 investigators filed a flurry of open records requests under the Freedom of Information Act, the Department of Insurance confirmed it had started looking into the Blue Cross decision to kick Springfield Clinic out of its network, and ruled that it was, indeed, a material change in network coverage.
“IDOI informed BCBS that it was a material change and would require a network adequacy filing by BCBS,” Department of Insurance spokeswoman Caron Brookens said in an email.
The state’s largest insurance company disagrees, and insists there was no “material change” in its network.
“Based on the law, we have a reasonable basis for our position that no material change occurred,” Miller wrote in an email last month.
After Target 3 investigators learned the state ordered Blue Cross to re-file its network for review, the company acknowledged the developments, but repeated claims that it followed the law.
“The Department requested, and we provided, updated network reports on March 3rd based on the departure of Springfield Clinic last year,” Miller responded. “We continue to believe that there has been no material change to our network under applicable Illinois law.”
“We want to be sure that we are holding the insurance companies accountable for providing accurate, up-to-date information about who is in and out of network so that people can make the right choices of doctors and hospitals,” Harris said.
Specialists sound alarm over hardball negotiations
Springfield Clinic doctors are not blind to the loss of patients in the waiting rooms. Internal medicine and pediatrics physician Dr. Kenneth Sagins – someone you could call a ‘Springfield Clinic staple’ – told us he’s tried not to get involved in the dispute between his employer and BCBS.
“I just want to be able to see my patients,” Dr. Sagins said.
“I mean, I’ve been seeing people for 20-25 years, and to not be able to see them anymore and have them leave, is a little bit troublesome,” he said.
The doctor estimated there are a couple thousand patients under his care, about 25% of whom are caught up in the corporate dispute. He fears the long term consequence could be a decline in health for his patients.
“From the studies, if anything you would read, having that patient-physician relationship over time really does improve outcomes,” Dr. Sagins mused.
On top of it all, connecting his patients to specialists has become a much larger hurdle and sometimes, there isn’t a single doctor available to whom he can recommend his patients.
“Having six to eight month wait times now, from the standpoint of any of your specialties, is not uncommon,” he continued. “We’ve had that happen in the last week.”
Prior to November, “It’s no comparison,” he said. “Before that, we could get people in within days.”
“It’s almost overwhelming the system at this point,” Dr. Sagins added.
Courtney Gray – whose one-year-old daughter is a patient of Dr. Sagins – shared her panic when her then 10-month-old got sick right after Blue Cross Blue Shield kicked Dr. Sagins and the rest of Springfield Clinic’s doctors out-of-network.
She tried to find a new doctor initially, but it didn’t last after she struggled to get them on the phone, another sign the few other providers in the area are seeing a sizable increase in patients.
“When you have a sick child, you have to get a hold of them,” Gray said.
The story ended with a trip to the emergency room. “She got bad enough to where we just had to go to the ER because we couldn’t get ahold of them, unfortunately,” Gray narrated, adding, “When it comes to your daughter’s health, you’re going to do what you have to do.”
“Not to sound old school or anything, but losing patients and not being able to see them after you’ve built up relationships for so many years is, on a personal level, extremely difficult. But I think also, on a professional level, is bad medicine,” Sagins concluded.
The loss of thousands of patients may be just as bad for business.
If the strategy is to shrink Springfield Clinic’s customer base, it appears to be working. A Blue Cross Blue Shield representative said its internal data showed two other hospital groups in the region reported a “more than 60% increase” in patients with BCBS insurance from December 2020 to the same month in 2021.
Rural doctors have seen this play out before. Other doctors we spoke to in the process of reporting this story warned low rates could drive specialists out of business, or at least out of town, dealing a blow to collective health in-and-around the capital city.
Doctors told us they retreated to Springfield Clinic from more rural areas to keep their practice alive. Blue Cross Blue Shield squeezed their rates so low back then that, according to the doctors, they had to close their doors.
“Those physicians in those rural communities have been driven out,” clinic VP Zach Kerker said.
“But there’s a huge population of people outside of the big cities that need to be taken care of,” Dr. Sagins said. “And they don’t want to travel two or three hours to get their care, nor should they have to.”
We asked the doctor with a decades-long career what would happen to healthcare and patients in the area if Springfield Clinic and its network of providers were to dissipate.
“Yeah, that’s a difficult question,” he responded, taking a moment to think. “Because in a lot of those situations, we actually send specialties out to the rural areas. We’ve got over 150 doc[tor]s that travel to the smaller areas – 90 different locations in central Illinois – and try to keep that local, and to keep that easier for the patients. Unfortunately, I think if they’re unable to do that, because of this, again, they’re going to be left, at minimum, traveling greater distances, whether it’s to Chicago, St. Louis, Peoria, some of those areas, to try to get this care.”
WATCH: The Bottom Line: Full 30-Minute Special Investigative Report