A third fine in fewer than two years for Illinois’ largest health
insurance company proves that stronger regulations are needed to prevent
insurers from promoting “ghost networks” of providers, state Rep. Sue Scherer
says.
“The fines
are not solving the problem,” Scherer, D-Decatur, said in response to the
Illinois Department of Insurance’s $231,900 fine announced Nov. 3 against the
parent company of Blue Cross and Blue Shield of Illinois. “The Department of
Insurance keeps fining them, but the problem isn’t going away.”
Scherer 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 in November 2021.
The bill
failed to muster the required 60 votes to pass the House and wasn’t debated in
the Senate.
Removal of
the approximately 600 clinic doctors, nurse practitioners, physician assistants
and other clinic providers in central Illinois from Blue Cross’ network was
part of a contract dispute between the company and the clinic that remains
unresolved.
Scherer, who
reintroduced her legislation as House Bill 4126 for consideration during the
spring 2024 session, said residents of the 96th House District told her they
found Springfield Clinic doctors and other doctors incorrectly listed in Blue
Cross’ online directories as in-network providers.
Insurance
department officials said in a news release that the latest fine was based on
Blue Cross not taking all corrective actions required when the department fined
Chicago-based Health Care Service Corp. $605,000 in March. State officials said
the company violated the Illinois Network Adequacy and Transparency Act.
Among other
findings, Blue Cross was cited for sometimes listing incorrect travel times to
providers in certain parts of the state, failing to provide the current status
of providers and not doing enough checking to make sure provider directories
were up to date.
The company
also “failed to provide a written response to written inquiries and complaints
within 21 days of receipt,” officials said in a March 9 news release.
HCSC paid the
$605,000 fine, but state insurance regulators said they still were able to
document incorrect status listings for four providers, triggering the $231,900
fine. Insurance department officials didn’t say where the four providers were
based.
State
officials said the company now is complying with the department’s earlier
order.
According to
the state, that order requires HCSC to create an improved search process within
its provider directories and say whether a provider is accepting new patients.
The order
also says that for providers who are in-network for facility or hospital
admitting rights only, those providers will no longer show up in specific
health plans, “to avoid confusing consumers who are searching for doctors and
specialists available for in-office visits.”
Blue Cross
spokesman John Simley told Illinois Times
in a statement that Blue Cross “strives to provide its members with an accurate
and usable provider directory.
“We recently
completed a series of updates to our online directories to make them easier to
use for our members and prospective members,” he said. “When we learn
information is inaccurate or incomplete, we fix it. Information related to the
four providers noted in the department’s order was corrected in May.”
Blue Cross
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 2022
action marked the first time the insurance department issued a fine in
connection with the Network Adequacy and Transparency Act. That law was enacted
in 2017 for health plans beginning Jan. 1, 2019, and beyond.
After the
latest fine, Illinois State Medical Society President Dr. Rodney Alford of
Watseka said in a statement the society is pleased to see Blue Cross held
“accountable for yet another violation” of the act.
“It’s
remarkable that this company continues to ignore the NAT Act’s requirements to
maintain up-to-date, accurate and complete provider directory information for
their customers – the patients of Illinois,” Alford said. “Inaccurate directory
information is frustrating to patients and leads to delays in care.”
Springfield
Clinic spokesman Zach Kerker said the clinic commends Gov. JB Pritzker’s
administration “for continuing to uphold laws that protect patients and hold
insurance companies accountable for violating network adequacy requirements.”
Kerker said
“dozens” of the clinic’s providers are incorrectly listed as in-network in Blue
Cross’ directories, “and it’s confusing to patients.”
Regarding the
contract dispute, Kerker added, “Springfield Clinic remains hopeful for an
agreement, as we have since BCBS removed us from their network two years ago.”
Simley, the
Blue Cross spokesman, said: “Springfield Clinic has well-respected providers in
its practice, and we would like to have them back in our network, but we need
to ensure that any new arrangement provides our members and employer groups
with the right value at a fair price. … The lines of communication are open,
and we look forward to new conversations.”
Scherer said
her bill would strengthen the state’s powers to hold insurance companies
responsible for treating customers fairly and promoting provider networks that
purport to be comprehensive.
Such “ghost
networks” are predominantly a problem in central Illinois but aren’t exclusive
to this part of the state, she said.
Fines aren’t
enough to improve service to consumers, Scherer said, adding that total fines
of slightly more than $1 million are insignificant to HCSC, which serves more
than 18.6 million members through plans in Illinois, Montana, New Mexico,
Oklahoma and Texas and reported almost $1.5 billion in profits in 2022.
“It’s like
one grain of corn in a whole silo,” said Scherer, whose district also includes
much of Springfield and parts of eastern Sangamon County.
Among other
things, Scherer’s bill would allow state officials to confirm the existence of
investigations of insurance companies and create more stringent standards for
maintaining accurate online lists of doctors in networks.
The bill also
would put in place time and distance standards more stringent than required by
federal requirements to ensure in-network access to specialists closer to
patients’ homes.
