Tuesday, May 24, 2005

Anthem & Premier…A Lost Hope

A while back, I wondered what would happen when United’s contract with Premier came up for renewal. Would the two sides reach an acceptable deal, or would Premier find itself cut off from BOTH of this area’s largest carriers?
Well, now we know: United and Premier have inked a deal seven months ahead of schedule. And this one’s a doozy – a 5 year contract, instead of the typical 3 year deal. This means that United customers who use Premier providers can breathe a little easier, knowing that they won’t find themselves in the same boat as Anthem insureds. And having such a long-term agreement in place means that the stress on everyone involved is put to bed for quite a while.
Well, not for everyone. Now that this deal is in place, it would appear that United is in position to take a good chunk of business away from Anthem. Why, you ask? Well, because United’s contract was due to expire this year, there was apprehension that they’d be in the same boat as Anthem, vis-a-vis Premier. Why jump out of the frying pan into the fire? But now that those fears are put to rest, employers can feel comfortable looking to United for coverage.
And there’s this: in the months since Anthem and Premier parted ways, more and more insureds are finding that they are affected by the split. The latest brouhaha involves emergency care. In theory, under Ohio law an emergency (defined by the “prudent layperson" test) must be covered as in-network, even if services were rendered by an out of network provider. But that’s not what’s happening:
"When chest pains scared Sharon Smith into Miami Valley Hospital's emergency room, it was less than a month after her cardiac stress test had found an abnormality in her heart.
It was also four days after Miami Valley's contract with her insurance company, Anthem Blue Cross and Blue Shield, had expired after failed negotiations.
But this was an emergency. Anthem had assured customers that emergency care would be covered at network rates. In Smith's case, Anthem also approved using Miami Valley for more expensive treatment.
The bill: nearly $15,000. Anthem sent her a check for $4,520.82.
About 100 Anthem customers a month are getting similar surprises after ER trips to Miami Valley or Good Samaritan Hospital, according to officials with Premier Health Partners. Premier is the parent organization over Miami Valley, Good Samaritan and Middletown Regional hospitals.
Anthem says that Ohio law doesn’t apply in this case; they maintain that they’re regulated under federal law, not state. Premier disagrees, and has filed a complaint with the Ohio Department of Insurance.
It’ll be interesting to see how that plays out.
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