* ISMS…
Illinois State Medical Society Statement on Insurance Co. “Ghost Networks”
Statement Attributable to Regan Thomas, MD, President, Illinois State Medical Society
The doctors of Illinois are concerned about recent reports of “ghost networks” perpetrated by state-regulated private health plans in Illinois. Insurance company provider directories often list doctors who are unavailable, not taking new patients, are located far away or who don’t work at the listed medical facility. This isn’t happening in just one part of Illinois, it’s a statewide problem.
We call on the Illinois Department of Insurance to enhance its enforcement of the ISMS-initiated Network Adequacy and Transparency Act, signed into law in 2017, including putting forth strict enforcement guidelines and penalties for non-compliance. This law provides important protections for patients, including continuity of care for those with ongoing and urgent medical care needs, such as cancer patients and expectant mothers.
ISMS also strongly calls for the insurance companies do a better job of keeping their published physician network information up-to-date as required by law. The inattention to this important task is impeding access to and continuity of healthcare, as well as the patient-physician relationship.
Illinois doctors urge patients to file complaints with the Illinois Department of Insurance whenever they experience these ghost network issues. Complaints can be filed online at https://www2.illinois.gov/sites/Insurance/Consumers/Pages/File-a-complaint.aspx.
* From a recent story by WCIA’s Mark Maxwell and Renée Cooper…
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.
Blue Cross is my health insurance company and most of my medical stuff is handled through Springfield Clinic, so I’ll refrain from commenting except to post this excerpt…
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.
- Bruce( no not him) - Friday, Mar 11, 22 @ 2:37 pm:
I will give credit to an unnamed Dr at Springfield Clinic. She gave me an extra long extension on a prescription, shortly before this happened, since she wasn’t sure I would be coming back because of the BCBS debacle.
I got the impression she wasn’t happy with either side in this battle.
- Almost retired - Friday, Mar 11, 22 @ 2:37 pm:
Private health insurance and manage care in private for profit companies goal is first to make money for owners and:or share holders. This should not be a surprise and has existed in Illinois manage care from its beginning to today.
- Demoralized - Friday, Mar 11, 22 @ 2:45 pm:
This is the kind of stuff that happens in a healthcare industry that’s driven by profits and not by actual healthcare.
- Gordon Willis - Friday, Mar 11, 22 @ 2:55 pm:
Enough finger pointing to go around several times. In my own experience with SC I do find a tendency to constantly refer patients to other specialists, much like a merry go round. Feels like they use patients as an ATM.
- Perrid - Friday, Mar 11, 22 @ 3:01 pm:
Everyone wants theirs. I don’t know enough about the dispute to really comment, except to say it sucks for patients when their provider and their insurer are feuding like this.
- Tom - Friday, Mar 11, 22 @ 3:18 pm:
It’s both sides. Get back to the table and resolve it. The clinic expected everyone to change insurers and that did not happen. BCBS expected the clinic to cave. That didn’t happen. BCBS should pay more to the good doctors at the clinic and resolve this. The clinics should stop being overly greedy.
- Mister Ed - Friday, Mar 11, 22 @ 3:27 pm:
Patients suffer the most when these types of issues arise. Profit driven healthcare is like any other business, it is basically looking out for stakeholders, not patients. I pray no one falls through the “cracks”. Medical bankruptcy is real folks and these people are struggling. BCBS, SC, ISMS please fix this.
- Sangamo Girl - Friday, Mar 11, 22 @ 3:29 pm:
The Ghost Networks are a big problem. The insurance companies deny responsibility and blame the inaccurate info on the providers. When I buy insurance I am paying the INSURANCE provider to provide me accurate information.
The WCIA reports are very good.
I have a relative with BCBS and now can’t find a primary care physician. One number on the BCBS provider list was a lawyers’ office. It is incredibly frustrating.
- Pot calling kettle - Friday, Mar 11, 22 @ 3:38 pm:
One solution is a national health care system. Stuff like this moves us a bit closer…I wish.
- Joe Schmoe - Friday, Mar 11, 22 @ 3:45 pm:
As an employer providing BCBS to my employees, and one who sees a specialist at Springfield Clinic, it’s been a nightmare. Employees dare not get pregnant and depend on a doctor at the Clinic or BCBS will force you out-of-network. Employees are scrambling to take care of special needs issues for their children because two for-profit entities are slugging it out for the biggest piece of the check. Both sides figured they’d win — the patients will lose either way.
- Merica - Friday, Mar 11, 22 @ 4:03 pm:
I’ve got nothing good to say about BCBS. With respect to Springfield Clinic, I feel the same way. it’s a monopoly set up specifically to fleece the taxpayer by charging the State more for State employee care. You would be shocked to see the physician salaries, rookie doctors making $400k per year not even working 4 weeks a month. The quality of care is not commensurate with the increased cost. I moved to SIU physicians after spending 4 years with a SC primary care doctor who i was never able to see in person (because he had too many patients) and constantly being incorrectly billed (for specialist care) when i went to prompt care. Not to mention often being asked to go to the ER by SC physicians for minor issues that did not require ER visits (in one instance a sinus infection, the other an ear infection). This controversy is like a fist fight between Vladimir Putin and MBS.
- AD - Friday, Mar 11, 22 @ 4:29 pm:
I’m baffled by Springfield Clinic’s inability to read the room in trying to bully BCBS. BCBS is the 800 pound gorilla for SC, SC is a rounding error for BCBS.
- 40,000 ft - Friday, Mar 11, 22 @ 4:31 pm:
Why do we not just leave behind insurance networks, their high deductibles, and their propensity to think they know more than your doctor?
If we went to an indemnity model, where you made a claim if you wanted, that would be an improvement.
Another improvement would be price transparency and let the consumer reward the best providers.
- MyTwoCents - Friday, Mar 11, 22 @ 4:37 pm:
For the amount of money spent on healthcare in this country (employee premiums, employer costs, out of pocket expenses, taxes paid to support Medicaid, Medicare and government employee health insurance, etc.) I honestly don’t see how some form of national health insurance could be any more expensive. I’m not arguing for a national health system like the United Kingdom, but more of a national Medicare system. That would eliminate petty disputes like this where the only losers are the patients stuck in the middle.
WCIA put together an excellent investigation that only highlights the ridiculousness of the provider networks. I hadn’t really heard of those ghost networks before, but some of those examples were truly extreme. I highly recommend everybody read the full article because how the BCBS list got that out of whack goes behind simple mistakes.