SPRINGFIELD, Ill. (WCIA) — There are few more relieving words than those from a doctor telling a patient they’re cancer free.

Jim Whaley and his wife Sharon walked hand-in-hand into the waiting room of HSHS St. John’s Pavilion in Springfield to get the final verdict from Jim’s Springfield Clinic radiation oncologist.

Sharon couldn’t wait the week between her husband’s scan and the appointment. She got a tentative confirmation he was in the clear over the phone the night before. Then a nurse practitioner confirmed, “It’s all great, great news. No cancer anywhere.”

“Yes!” Jim said with fist pump, knowing he’s leaving squamous cell carcinoma (a type of oral cavity cancer) behind him.

Relief was visible on Sharon’s face. She said her husband nearly quit during the final days of radiation treatment.

“He said, ‘I’m done. I can’t do anymore.’ And we’re like, ‘You’ve got three more. Just three more,'” she remembered encouraging her husband of nearly 40 years.

“We can breathe again.”

The celebration was brief. Eight months after the diagnosis, with surgery and dozens of daily radiation treatments in between, the Springfield electrician, husband and father is already back to work, and back to worrying about the growing pile of bills from his health insurer — Blue Cross Blue Shield of Illinois.

That story traces back to November when BCBSIL kicked Jim Whaley’s Springfield Clinic radiation oncologist out of network a month after he was first diagnosed and preparing for treatment.

Target 3 investigative reporters revealed that contract termination between the clinic and BCBSIL — the largest insurer in the state — knocked every radiation oncologist in the capital city out of network, forcing the Whaleys and countless other patients to choose between accessible, life-saving healthcare and their life savings.

There are protections under state and federal law to keep bills at an in-network rate for patients like Whaley whose lives are threatened by the loss of affordable healthcare. Regardless, Sharon said somewhere in the range of “$40 to $52,000” in charges listed in Explanations of Benefits (EOBs) from BCBSIL have landed on their doorstep this year.

The cost of Jim’s treatment now far exceeds the $3,800 out-of-pocket maximum printed in black and white on the back of his insurance card.

“Every time you call Blue Cross, it’s ‘What you owe is what you owe, we don’t have anything to say about it,'” Sharon said immediately following Jim’s late May check-up.

In March, the Whaleys sent appeals to BCBSIL and the U.S. Department of Labor, the agency equipped with regulatory power over group health insurance plans like the one that the Whaleys are enrolled in through Jim’s union of 17 years, the National Electrical Contractors Association (or NECA-IBEW). The union also received an appeal from the Whaleys.

“If anybody’s ever filed an appeal, it’s unreal. I mean, a stack of papers that thick,” Sharon said gesturing about an inch stack with her fingers. “When you do that for 40 radiation treatments, it’s like, whoa.”

John Simley, director of communications for BCBSIL, said in the case of “plans that are funded and administered by employers, labor unions and other organizations…member claims and appeals are not reviewed by BCBSIL.”

Grant Vaught, listed as an earnings and benefits media contact for the U.S. Dept. of Labor, also placed the responsibility for appeal review on the union.

“Under ERISA, group health plans must run a process for the review of claims decisions that meets regulatory requirements for a full and fair review process,” Vaught said in an email, adding, “As part of those ACA requirements, plans and issuers must also provide external review for adverse benefit determinations.  In many circumstances, this means that the review must be conducted by an independent review organization.”

It’s unclear whether the review process by NECA representatives has begun. A lawyer for the union — John Long of Cavanagh | O’Hara, LLP in Springfield said, “the Plan cannot comment on media inquiries regarding any individual’s health treatment due to federal privacy laws.”

“It’s low on the list right now,” Sharon said. “So they may not get to it until October,” which would be 13 months after Jim’s diagnosis.

“We have no answers,” Sharon responded when reporters asked why would it take the union half a year to get around to reviewing.

Unions also have the ability to opt-in or out of certain benefits when they purchase a large-scale plan like the BCBSIL plan NECA-IBEW offers its members.

One of those possible provisions would allow for continuity of care, meaning patients with life-threatening medical conditions — like Jim Whaley — would be able to keep their doctors at an in-network rate for up to three months after a contract is terminated between their insurer and provider.

A NECA representative confirmed over the phone to reporters that they do not offer continuity of care, something that could’ve saved the Whaleys thousands of dollars and countless hours fighting those costs.

“They could be the hand that really forces it by saying, ‘Hey, you know what, we’re a big organization. We pay you a lot of money, pay the bills,'” Sharon said.

The federal No Surprises Act was updated — two months after Jim’s oncologist fell out of network — to require unions and other groups to include continuity of care provisions in plans.

“These provisions are applicable with respect to plan years (in the individual market, policy years) beginning on or after January 1, 2022,” Vaught said in reference to FAQS ABOUT AFFORDABLE CARE ACT AND CONSOLIDATED APPROPRIATIONS ACT, 2021 IMPLEMENTATION PART 49 published in August by the U.S. Employee Benefits Security Administration.

That would appear to mean Jim’s bills dated after the first of the year should be covered at an in-network rate.

However, federal agencies — including the U.S. Department of Labor and the U.S. Department of Health and Human Services –noted in July that “any such rulemaking to fully implement these provisions will include a prospective applicability date that provides plans, issuers, providers, and facilities, as applicable, a reasonable amount of time to comply with new or clarified requirements,” leaving the final deadline somewhat murky.

The same NECA representative assured the union would come into compliance by the unknown date.

“When you’re 58 years old and you can retire in a couple of years, you really don’t have time to vest in anything else,” Sharon said in frustration over the lengthy appeal process.

At the end of the day, BCBSIL is responsible for selling a plan with an adequate network of providers.

“I don’t think it’s fair for the insurance company to ask you to go see a radiologist in Chicago,” Jim mused. His wife added, that would be a daily three-hour commute during radiation treatment, which appears to be in the past for the Whaleys. Although, Jim is on the hook for follow-up appointments every other month for the foreseeable future.

“He would have loved to been out of his physical labor job at 60,” Sharon said.

“Not the way it is now,” Jim added. “Yeah, not an option,” his wife agreed.

Representatives with Springfield Clinic said they’re holding off on billing the Whaleys while the appeal process continues.

Both the clinic and BCBSIL claimed they are still at the negotiating table.

Full statement from Springfield Clinic:

Springfield Clinic was hopeful that new leadership at Blue Cross would bring a more collaborative approach to negotiations. Unfortunately, BCBSIL’s latest proposal is a significant move in the wrong direction on a potential compromise.

Full statement from Blue Cross Blue Shield of Illinois:

Blue Cross and Blue Shield of Illinois has been working with Springfield Clinic for nearly a year to reach a deal that ensures our members have access to the quality care they need at affordable prices. We proposed an arrangement to the Clinic that would deliver quality and value for our customers and members but, to date, the Clinic has not shown interest in such an arrangement. 

Blue Cross reprocesses new mother’s bills days after reporters press for answers

Elizabeth Farris-Byerline — now a mother of two — said her fight with her insurer (BCBSIL) has taken a turn for the better, but she believes she’s being used as a ‘scapegoat’.

Farris-Byerline was one of more than 100,000 patients whose Springfield Clinic doctors haven’t been covered by their health insurance since mid-November. That’s around the time the expectant mother applied for continuity of care through BCBSIL. State law requires continuity of care to be provided for pregnant moms in their third trimesters — like Byerline was at the time — all the way through post-partum.

Until May 27, Byerline had only received verbal confirmation that she would be covered. More than $3,500 in EOBs from BCBSIL arrived in the mail shortly after she delivered her daughter, Elena, on March 16.

Then, things turned around Tuesday. Byerline showed reporters a letter from her insurer that said her charges have dropped from more than $3,500 to $20 in total.

“I mean, they’re definitely covering their tracks here,” Byerline said, frustrated by the timing of the reprocessing of her claims.

It came just a week after reporters started probing BCBSIL communications representatives about why the company still appeared to be out of compliance with state law by charging mothers in their third trimesters at out-of-network rates. Days after reporters provided the insurance company with Byerline’s name to check into her case — albeit as a part of a larger apparent pattern — she got a call from BCBSIL promising the reprocessing. The official letter arrived Tuesday.

“My husband’s like, ‘I feel like the mob just silenced us. Like they don’t, they just want to kill the story. They don’t care how they’re going to do it.’ He’s like, ‘I just I feel like we’re not supposed to talk about it, or else they’re gonna take it back,'” Byerline expressed. “I mean, there’s like a part of me that thinks that. But then I also think about how many other people are like me, or going to be like me?”

A statement from Springfield Clinic says at least 120 other patients were in the same position.

“Springfield Clinic providers have delivered over 200 babies for patients with BCBS insurance since going out of network November 17, 2021.  Over half of them (120), were within the first 90 days of going out of network.”

Simley, the director of communications for BCBSIL said, “195 members with pregnancy or pregnancy-related diagnoses were approved for continuity of care with Springfield Clinic,” when pressed about the pattern apparent in Target 3 reporting.

However, Byerline remains the only one of several mothers reporters have personally spoken with who 1) received a letter from BCBSIL confirming the approved care, and 2) have actually received a reprocessed claim at the in-network rate, something she agonized over for two months after her baby was born.

Reporters spoke with another mother Tuesday, Amanda Lawler, who was also in her third trimester at the time of the termination between her insurer — BCBSIL — and Springfield Clinic. Lawler was also given a verbal continuity of care promise months ago. She said Tuesday she continues to receive bills that “are not in-network prices,” and never got a letter confirming continuity of care.

If you’re a mother with BCBSIL insurance who has received or is fighting to get continuity of care, we want to hear from you. Email us at target3@wcia.com.

BCBSIL was required to refile its provider network with the Illinois Department of Insurance after our reporting revealed a dead-end directory of doctors. That review process began two months ago. A representative with the Dept. of Insurance said it’s ongoing and “the Department does not comment on filings that are under review,” adding, “When the Department’s review is complete, we will provide an update at that time.