A contract dispute meant that Springfield Clinic was an out-of-network provider for people insured by Blue Cross and Blue Shield of Illinois for about two years. The clinic will return to in-network status on Jan. 1, 2024.
Chicago-based Blue Cross and the clinic issued statements Dec. 22 that they have reached a new five-year agreement allowing the clinic to return to in-network status.
Springfield Clinic patient Judy McEvoy said the news was “a Christmas miracle of a sort.”
The 56-year-old Springfield resident decided to pay more than $1,000 in out-of-pocket charges so she could keep seeing two clinic doctors – her family physician and obstetrician-gynecologist – even after they became out-of-network providers in her employer’s Blue Cross plan.
“I’m over-the-moon happy about it,” she told Illinois Times. “It’s going to save me money in the long run, and I can use my insurance as it’s supposed to be used.”
A contract dispute prompted Blue Cross to remove the clinic and its 400 physicians and 300 advanced-practice registered nurses and physician assistants from Blue Cross’ preferred-provider network in November 2021.
The for–profit clinic estimated at the time that Blue Cross’ decision would affect 100,000 clinic patients throughout central Illinois, while Blue Cross officials said the correct number was not more than 55,000.
Neither side revealed details of the new contract or what led to a resolution of the dispute. Springfield Clinic wouldn’t say how the dispute affected the overall number of patients using the clinic.
McEvoy, an administrative assistant at Hanson Professional Services Inc., said she always held out hope that the clinic would return to in-network status. She doesn’t care how the two sides worked out a deal.
“You don’t need to know how the sausage is made,” she said. “Overall, it’s a benefit for all of Springfield and the surrounding communities.”
The saga included months of testy statements from each side directed at the other.
Blue Cross publicly complained that the clinic was demanding a 75% increase in rates even though the clinic’s rates were already the highest in the Springfield markets and 60% more than those in the Chicago area. Blue Cross said giving in to the clinic’s demands would result in Springfield-area small businesses that are Blue Cross customers picking up the slack and seeing increases of up to 30% in their premiums.
Clinic officials never responded directly to those assertions by Blue Cross.
But in letters to patients in 2021, the clinic – which operates medical practices in Springfield and in communities that include Carlinville, Jacksonville, Lincoln, Sherman and Taylorville – criticized Blue Cross’ stance in contract negotiations and implied the company was greedy.
Clinic officials noted at the time that Blue Cross’ parent company, Chicago-based Health Care Service Corp., was earning record profits during the COVID-19 pandemic.
Blue Cross, like many insurers nationwide, benefited financially because premiums continued to be paid by employers and workers while many patients delayed or avoided health care services for fear of being infected by the novel coronavirus.
“At a time when countless individuals, families and businesses in our communities have faced financial challenges and hardships, it is unimaginable that BCBSIL would terminate Springfield Clinic as an in-network provider," the letter to patients said.
The situation led to surges of patients seeking care at physician groups that remained in the Blue Cross network, such as those at Southern Illinois University School of Medicine and Memorial Health. Patients sometimes faced long waits for non-emergency care as they tried to avoid hefty out-of-pocket charges for remaining with their longtime Springfield Clinic providers.
Some employers that had contracted with Blue Cross switched to other insurers so their employees could retain in-network access to Springfield Clinic.
The General Assembly became involved, too, as it considered whether more regulation of health insurance companies was warranted. No action was taken, but more debate is expected in the Legislature’s spring 2024 session.
The rift between the clinic and Blue Cross, the state’s largest health insurance provider, ultimately led to $1.1 million in state fines against Blue Cross’ parent company.
Health Care Service Corp. paid a March 2022 fine of $339,000 for failing to notify the state in 2021 about the removal of Springfield Clinic as an in-network provider. The Illinois Department of Insurance fined HCSC $605,000 in March 2023 for violating the Illinois Network Adequacy and Transparency Act. And a fine of $231,900 was issued on Nov. 3 for failure to take all corrective action after the March fine.
In the latest fine, Blue Cross was cited for sometimes listing incorrect travel times to providers in certain parts of the state in online directories and not doing enough checking to make sure provider networks were up to date.
Blue Cross said in its Dec. 22 statement that it was “glad to have Springfield Clinic back in our network starting Jan. 1, as part of an agreement that preserves access to quality health care for our members and employer groups.”
The statement added: “The clinic has more than 650 well-respected medical professionals who once again are part of our network of more than 130,000 providers across Illinois. This will continue our focus on providing broad access to health care providers for our members and customers across the state.”
People with questions about their coverage should call the phone number on the back of their Blue Cross insurance card on or after Jan. 1, the Blue Cross statement said.
Springfield Clinic said on its webpage that people who have questions about insurance plans and in-network status should contact the clinic’s Patient Advocate Center at 217-391-7086 after Dec. 26.
The new agreement pertains to most Blue Cross plans except for Blue Choice, which is offered to state workers and people receiving coverage through the Affordable Care Act’s online health insurance exchange.
ILLINOIS HOUSE DEMOCRATIC CAUCUS
Rep. Sue Scherer, D-Decatur, tried but failed in April 2022 to pass a health insurance reform bill in the Illinois General Assembly amid complaints from constituents who were Blue Cross members and were having a hard time locating in-network doctors after their Springfield Clinic doctors became out-of-network providers. She has reintroduced her legislation for consideration during the spring 2024 session.
State Rep. Sue Scherer, D-Decatur, who saw her insurance reform bill fail in the House in April 2022, said she reintroduced the legislation as House Bill 4126 and plans to make another push for passage in 2024.
The 104-page bill would allow state officials to confirm the existence of investigations of insurance companies. It also would create more stringent standards for insurance providers to maintain accurate online listings of doctors in their networks and more quickly adopt annual federal recommendations on the number of specialty doctors needed for “network adequacy.”
Scherer said many of her constituents called her to say they had a hard time finding in-network doctors within a reasonable distance and found flaws in Blue Cross’ online directories. Other constituents paid out-of-network fees to keep their longtime Springfield Clinic doctors before the contract dispute was resolved.
After learning the clinic will return to in-network status with Blue Cross, Scherer said she was “doing my happy dance.”
She said her push for legislation “shed a light” on the need for more regulations on health insurers to protect patients.
Scherer said she met separately with Blue Cross and Springfield Clinic officials to push them toward a compromise. She issued a news release taking some credit for the new contract.
The release said Scherer “helped to establish an agreement that restores care to many Springfield Clinic patients.”
Scherer was quoted in the release as saying, “Still, there’s more work to be done. And I will never stop fighting to hold big health insurance companies accountable.”
Scherer’s bill, if passed, would “establish stiffer penalties for health insurance companies’ inability to update provider lists as quickly as possible,” the release said.
“Companies’ failure to do so has created ‘ghost networks’ where a patient’s listed health care providers have moved away or are now out-of-network,” the release said. “As a result, patients, especially in central Illinois and rural communities, have to travel great distances to receive essential care.”
Mike Murphy, president and chief executive officer of the Greater Springfield Chamber of Commerce, called the new agreement between the clinic and Blue Cross “a big win for the citizens of our area.”
The Springfield area’s greatest potential for economic growth in the next decade or two will be in the health care community, he said. Resolving strife in that community is in everyone’s best interest, he said.
“No one was a winner the past two years,” Murphy said. “We don’t want any negatives. … I want to make sure all of our providers are operating at 100%. I want them all to be clicking.”
Dean Olsen is a senior staff writer at Illinois Times. He can be reached at [email protected], 217-679-7810 or twitter.com/DeanOlsenIT.
