People insured by Anthem BlueCross BlueShield in Colorado may not have access to in-network coverage at Centura Health facilities – which includes Mercy Regional Medical Center – unless an agreement is reached before May 11.
According to a letter sent to members on March 24, Anthem says it has been unable to reach a new contract agreement with Centura, and the two companies have also failed to extend the current agreement. The previous deadline was May 7, but an Anthem company spokesman said Wednesday the date has been extended three days.
If an agreement on a new contract or extension is not reached by midnight on May 10, most of the Centura Health Providers will no longer be participating in Anthem’s network, the company spokesman said.
Centura Health is Colorado’s largest health system, operating 17 hospitals with more than 100 practices and clinics, two senior living communities and the Flight for Life emergency medical helicopter transport.
In Southwest Colorado, Centura’s Mercy Regional Medical Center, according to its website, is the region’s “largest and most technologically advanced medical facility.”
Likewise, Anthem is the second largest insurer in Colorado, according to a Department of Insurance Health Care Cost Report. An Anthem company spokesman said there are about 1 million Anthem members across the state.
“It definitely would be a problem if the main health provider and a leading insurer in the Four Corners could not come to agreement,” said Joe Hanel, manager of public policy outreach for Colorado Health Institute.
“This situation highlights the potential for problems when communities have few choices in both health care and health insurance.”
On Wednesday, representatives for both Anthem and Centura said the two sides are negotiating, and progress is being made. According to Anthem’s letter, the company is required by the state to send a letter of notification out 45 days in advance in these type of contract situations.
“The majority of the time our negotiations with providers reach a successful conclusion before the deadline, but we want you to be aware of the situation as it currently stands,” the letter says.
Both companies declined to discuss the particulars of the contract negotiations, though Anthem’s Tony Felts provided a comment that indicates the debate revolves around reimbursement rates.
“In general, all insurers have contracts with hospitals that detail reimbursement rates that they (insurers) will pay to hospitals on behalf of the medical services the hospitals provide to the insurer’s members,” he wrote in an email to the Herald. “The contracts are usually multi-year. When the contract nears expiration, negotiations on a new contract begin, which describes the current Anthem-Centura Health situation.”
To say that Anthem dropping Centura from its network would have a significant impact on residents in Southwest Colorado, as well as across the state, would be an understatement, said Adam Fox, with Colorado Consumer Health Initiative.
Mercy, by far, is the largest medical provider in Southwest Colorado, operating a 212,200-square-foot hospital with a capacity of 82 beds, and offers 135-board certified physicians representing 35 medical specialties and sub-specialties. It also boasts being one of the largest employers in Durango, with more than 800 full-time staff.
“There aren’t really many (if any) provider/hospital options in the area, so that means members could face extremely long travel to see an in-network provider,” Fox said.
“It also raises the question as to whether Anthem will be able to meet network adequacy standards put in place last summer, and if not, it’s unclear how DOI (Department of Insurance) would react.”
Last year, the state’s DOI put in place regulations that require insurers to provide reasonable access to care, called “network adequacy,” based on a number of factors, including geographical challenges.
Representatives with DOI said Wednesday if an insurer loses a major hospital provider in its network, the insurer must then provide a plan of action of how it plans to continue care to its members.
“As with contract disputes in all walks of business, there’s always an element of who blinks first,” said Vince Plymell, communications manager for the DOI.
Regardless, contract negotiations that go down to the wire leave Southwest Colorado residents in limbo, unsure whether to shop for a new insurance plan or look for other alternatives.
“To not be able to go to our main hospital for fear of being dinged with out-of-network charges is pretty significant,” said Anna Riling, a Durango resident and mother of two children. “And the reason I went with Anthem is I thought with a giant insurance company, I’d be safe from this kind of thing happening, but I guess not.
“It’s scary.”
jromeo@durangoherald.com
