Copies of Bills for Blue Cross for 2018

• BlueCross and Anesthesia Medical Group have until Sept. 1 to cut a deal.
• If they don't, non-emergency anesthesia costs will rise for most Middle Tennessee patients.
• Pregnant women who want an epidural but don't want to switch hospitals are likely most affected.

Eight months into her pregnancy, Halie Gallik is faced with a tough choice: switch hospitals, leaving behind the doctors she has grown to trust, or face a "surprise" bill that could cost thousands.

Gallik, 32, of Nolensville, is expected to give birth to her third child in late September at Williamson Medical Center, a hospital close to home where her two other kids were born. But Gallik's insurance is shifting beneath her feet, and soon a birth at Williamson may cost her more than ever.

"We already have an established relationship with our doctor and familiarity with that hospital," Gallik said. "Even though I would go to an in-network doctor at an in-network hospital, now they could still bill me for an extra $2,000 — or potentially more. That's crazy."

Gallik is one of many pregnant women and surgery patients caught in the middle of a corporate tug of war that threatens to cost them hundreds or thousands in unexpected medical bills. Unless two giant companies broker a peace agreement soon, patients throughout Nashville and Middle Tennessee will end up paying more for anesthesia during non-emergency surgeries, including births.

BlueCross vs. Anesthesia Medical Group

This abrupt rise in out-of-pocket costs is the result of stalled negotiations between the state's largest insurance company, BlueCross BlueShield of Tennessee, and the state's largest anesthesiologist company, Anesthesia Medical Group, or AMG, which works in nearly every hospital in Middle Tennessee. The companies have been unable to agree on lowered insurance reimbursement rates, which Blue Cross says would lead to savings for customers. So the insurance company plans to remove AMG from its coverage network if a compromise is not reached by the end of the month.

Both companies declined to discuss the negotiations in detail, saying only that there were offers and counteroffers, followed by a period of stalemate then renewed negotiations. Officials from both companies said they "hold out hope" for a deal but acknowledge the Sept. 1 deadline is fast approaching.

"We know that no one wants to be here," said Roy Vaughn, a senior vice president of BlueCross. "But these negotiations started a long time ago, and when you have one side looking for an increase, and one side looking for a decrease, it's going to be tough."

AMG Chairman Dr. Stephen Santi disputed the claim, saying the company proposed a rate decrease, not a rate increase, but that BlueCross demanded a larger decrease.

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If AMG is dropped from the insurance network on Sept. 1, many BlueCross customers who receive anesthesia from an AMG doctor during a non-emergency surgery will have to pay a larger percentage of the anesthesia bill themselves. Anesthesia performed by AMG doctors would then be covered at an out-of-network rate, even if the procedure is performed at an in-network hospital.

BlueCross officials said it is difficult to broadly estimate the cost of this change because of the wide variety of insurance plans and medical procedures. However, when pressed for an example, the officials estimated that a hypothetical patient's insurance coverage would drop from covering about 80 percent of their anesthesia bill to only about 60 percent. Anesthesia bills can easily cost several thousand dollars.

The network change will have no impact on anesthesia for emergency care, which BlueCross said is always billed at an in-network rate. The change also will not affect coverage that stems from TennCare or Medicare.

Medical bills could come as a surprise

BlueCross alerted its policyholders to the stalled negotiations with AMG about six weeks ago, back when it felt as if there was still plenty of time for a compromise.

But that never happened. And as the deal deadline has crept closer with each passing day, both companies have taken steps to alert patients to the looming changes — including blaming each other for the stalemate on their respective websites.

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Despite these efforts to get the word out, BlueCross and AMG admit that many customers are likely still unaware that their medical bills might increase. Some patients, they fear, will find out the hard way — when the surgery is done, then a hefty bill arrives.

"We are trying to educate patients, so it is at least not a surprise," Santi said in an interview Monday. "As a consumer, no one wants to feel like they have to pay more for something and not understand why. That's very concerning for us as well."

Vanderbilt University Medical Center, the largest hospital in Middle Tennessee, is immune to the billing charges because it employs its own anesthesiologists. But the impact will still be felt widely because AMG anesthesiologists work in most if not all TriStar, Saint Thomas and Tennova hospitals — and their outpatient surgery centers.

BlueCross customers who have surgeries scheduled at these facilities after Sept. 1 have a few options:

• Submit a "network benefit request form" to BlueCross, essentially asking for an exemption that would treat AMG anesthesiologists as in-network even though they are not. BlueCross officials said the exemption forms would be considered, but made no stronger commitment.
• Discuss your scheduled surgery with your personal physician and possibly AMG, which has said it will consider offering patients discounts for pre-payment or financial hardship patients on a case-by-case basis.
• Or attempt to transfer your surgery to an in-network hospital — like Vanderbilt — that does not employ AMG anesthesiologists, and therefore will be considered in-network by BlueCross. Some Saint Thomas hospitals employ a mix of AMG and non-AMG anesthesiologists, so the hospital chain has said it should be able to accommodate BlueCross customers so their out-of-pocket costs don't increase.

But these options — none of which are guaranteed solutions — are likely little comfort for pregnant women like Gallik, who are among the most affected by the anesthesia standoff.

Expectant mothers often build a longstanding relationship with their OB-GYN, so switching hospitals in the middle of a pregnancy can be daunting. On the other hand, most women opt for an epidural, which is a form of spinal anesthesia that costs upward of $3,000. At nearly every hospital in Middle Tennessee, there is a high likelihood that epidural would be performed by an AMG doctor.

Gallik said she was first alerted to her situation in late June when BlueCross informed its customers that negotiations with AMG had stalled. Concerned, Gallik said she contacted Williamson Medical Center and BlueCross to find help but so far has found none.

Most often, Gallik said, officials told her not to worry because it was most likely the two companies would work out some sort of compromise. But as their deadline encroaches, with her due date not far behind, hope for a last-minute deal has dwindled.

"I just have to sit and wait, because there is literally no one else to call and complain to," Gallik said.

"And I don't know if AMG is correct in saying that BlueCross is bullying them. And I don't know if BlueCross actually has my interest at heart and is trying to protect me. But the bottom line is that I'm pregnant, I'm going to have a baby, and I don't want a surprise $2,000 bill."

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Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. Follow him on Twitter at @brettkelman.

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Source: https://www.tennessean.com/story/news/2018/08/15/blue-cross-blue-shield-tennessee-anesthesia-medical-group/956902002/

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