Empire BC/Stellaris Health contract wars

[Guest hoss]

4 hospitals may drop Empire Blue Cross

By Jerry Gleeson

The Journal News

(Original Publication: December 6, 2006)

Patients who find themselves having disputes with Empire Blue Cross Blue Shield have some recourse with state regulators in the event that the insurer and the Stellaris Health Network cannot reach a new contract by Jan. 1.

The state Insurance Department has a consumer hotline that operates 9 a.m. to 5 p.m. Monday through Friday. The number is 800-342-3736.

Complaints also can be filed at the Insurance Department's Web site. Go to www.ins.state.ny.us, click on the "Consumers" and then click on "Health." Go down the page and click on "How to file a complaint or make an inquiry."

In the latest episode of contract negotiations that could leave patients scrambling for medical service, four Westchester County hospitals have signaled their intention to withdraw from Empire Blue Cross Blue Shield on Jan. 1.

Without a contract, Empire patients would have to pay out of their own pockets to use White Plains Hospital Center, Northern Westchester Hospital in Mount Kisco, Phelps Memorial Hospital Center in Sleepy Hollow and Lawrence Hospital Center in Bronxville.

Empire patients may find that some of their doctors have been dropped from Empire's network as well. Empire sent a letter to some doctors on Oct. 30 warning that it would happen if they lacked admitting privileges at a hospital outside of the chosen four.

Empire said yesterday that Medicare members enrolled in its HMO and PPO Medicare Advantage plans are not affected. Both sides have settled coverage for that portion of the contract, it said.

It was unclear yesterday how serious a problem the Jan. 1 deadline poses for other patients.

Empire, the largest health insurer in the state based on PPO and HMO membership, has other Westchester doctors and hospitals in its network. In its Oct. 30 letter, it urged doctors to contact the insurer to arrange for continued care if their patients are affected.

Yesterday, both Empire and Stellaris Health Network, the Armonk organization that represents the four hospitals, issued statements maintaining that the contract talks were continuing in good faith. Both said they were hopeful a deal could be reached before Jan. 1.

Last year, however, Empire and the network representing Good Samaritan Hospital in Suffern allowed their contracts to expire for a single day while they wrangled over a new deal. The contract was settled three months later.

In 2004, patients under United Healthcare faced a similar threat when that insurer and five Westchester hospitals argued over a new agreement. Both sides struck a deal before the deadline set by the hospitals.

One doctor said yesterday that he expects Empire and the Stellaris hospitals will reach a deal before month's end. He and other medical professionals, however, were unhappy over the effect the negotiations were having.

"It's unconscionable to have patients who paid premiums all of a sudden not be able to find a doctor," said Dr. Michael H. Rosenberg, a plastic surgeon and former president of the Medical Society of the County of Westchester.

Three of the eight doctors at his practice, Plastic and Reconstructive Surgery in Mount Kisco and White Plains, are affected by the Empire-Stellaris contract, he said. The practice plans to send letters to patients on Monday notifying them of the possibility that they would need new doctors on Jan. 1, he said.

Rosenberg called Empire's letter to the doctors "pretty outrageous." It was the first time he had seen such a letter in the course of contract discussions between hospitals and insurers. Rosenberg said doctors and patients are being used as pawns in the talks.

"Here, they've raised the stakes," he said. "There's a tremendous amount of brinksmanship, and Empire is very powerful ... but at the end of the day, are they really going to throw out 15,000 patients? I hope not."

Neither Empire nor Stellaris would comment in detail on the issue, saying it could affect negotiations. Empire said it doesn't report on the number of patients it has by a particular geography.

Reimbursement rates commonly are high on the list of issues between hospitals and insurers when new contracts are negotiated. Many in the Lower Hudson Valley have complained that they receive less from insurers than hospitals in Connecticut and New Jersey get for the same procedures.

Empire and Stellaris downplayed the actions they had taken in the talks up to this point.

The notification of the canceled contract is "sometimes required by both Stellaris and the Managed Care Organization triggered by various contract terms and/or regulatory agencies," the Stellaris statement said.

Empire defended its Oct. 30 letter to the doctors in similar terms.

"Notification to some physicians is a contractual requirement, and does not mean that we will not reach agreement, just that at this time we are still in discussions," the statement said.