7 Investigates: Patients caught in confusion as Aspirus responds to federal Medicare surprise billing protection rules

(WSAW) - It began with what looked like a bill in the mail this summer. A couple in Antigo was confused; the document from Aspirus addressed to the husband laid out thousands of dollars worth of estimates for appointments, but they had already met his deductible and out-of-pocket maximum for the year after having cancer-related surgery this spring.

This couple reached out to 7 Investigates, requesting not to be identified for fear of retribution. In Antigo, there are not many options for health care outside of Aspirus. They began receiving notices from Aspirus that their insurance plan was out-of-network, asking if they continue with their care at Aspirus that they consent to pay the difference insurance does not cover.

The husband retired from what is now Verizon too long ago to remember exactly when. The couple receives health insurance coverage through the Verizon Advantage Plan, provided through Aetna. They liked their coverage for its affordability and it allows them to care for their needs with providers they have built relationships with in Antigo.

Other people on the insurance plan had also begun to see some unusual things. All patients or members who spoke with 7 Investigates related to the Verizon Advantage Plan asked not to be identified for concern of retribution or privacy. One of them was asked to pay upfront when he arrived at Aspirus before being seen for his appointment, and did, paying about $400.

Another couple also found out when they showed up for an appointment. The husband in that household is diabetic and was told that appointments in his plan of care related to that would continue to be covered, but if he came for any other appointment at Aspirus, they would be charged the out-of-network difference.

The wife from the first couple spent hours on the phone trying to understand what was happening. She contacted Verizon, Aetna, and Aspirus trying to find answers, with little luck. The number of sticky notes and napkin scribbles bear the numbers and names of more people who had no idea what was going on. Then, she reached out to Kathy Schultz, the elder benefits specialist at the Central Wisconsin Aging and Disability Resource Center.

“We’re the advocates for the elderly, basically,” she told 7 Investigates.

Schultz, who has been a benefits specialist for 22 years, heard from several people in this group, confirming most people found out about the out-of-network change when they showed up to appointments; not through notification of any of the parties involved.

“It’s not that they lost insurance coverage; that’s not the issue at all. It’s, it’s the provider and the network,” she explained. “And for some folks, they would have to travel a minimum of 30 miles one way to get medical help to stay within the network. They don’t want to lose their insurance, their insurance is good. They are a retiree group. So it’s a little different than other folks who are just in Medicare.”

The difference: those retiree group benefits are difficult, if not impossible to rejoin if any of these members decide to switch to different coverage.

The message communicated through the many calls was that Aspirus had dropped out as an in-network provider. Turns out, that grapevine message was not quite accurate, but that was the understanding members received and had for weeks. Patients did not know what to do and waited in limbo for answers, wondering if they would have to change their coverage to get the care they need, but it was not the open enrollment period yet. They wondered if they would have to hold off going to appointments or go elsewhere in the meantime.

“I’ve not run across before a provider being out of network mid-year,” Schultz expressed.

It took Verizon, Aetna, and Aspirus weeks to provide 7 Investigates answers to these patients’ questions too. In September, Verizon said it was working to understand the local situation in Antigo, adding that the advantage plan serves more than 175,000 retirees across the country. Three weeks later, Verzion provided a statement urging any more questions be directed toward Aetna.

Based on information Aetna has provided Verizon, there are currently seven Aspirus locations that accept the Verizon Advantage Plan. Members will pay the same co-payments and co-insurance as if the providers were in-network.

Aspirus locations accepting the plan include:

• Aspirus Eagle River Hospital

• Aspirus Merrill Hospital

• Aspirus Stanley Hospital

• Aspirus Tomahawk Hospital

• Aspirus Rhinelander Hospital

• Aspirus Stevens Point Hospital

• Howard Young Medical Center

For the remaining Aspirus locations that may choose not to bill claims through the plan, members can still visit for service and submit the bill to Aetna for review. Verizon’s Medicare Advantage plan provides coverage for any doctor or facility that accepts Medicare. While Aetna maintains a network, there is no difference in the level of coverage provided to retirees who seek services in-network or out-of-network.

Aspirus Langlade County was not on the list. The next day, Aspirus in a brief email stated Aetna Medicare Advantage plan members were considered in-network after reaching an agreement at all Aspirus locations. However, that did not explain what caused this gap in the first place or what patients who paid over those weeks when their insurance would have covered it otherwise.

On Oct. 20, Aspirus’ chief financial officer and senior vice president of finances, Sid Sczygelski agreed to interview. He said federal regulations going into effect at the beginning of 2022 caused Aspirus to review their patients’ insurance coverage. The No Surprises Act puts more requirements on providers to inform patients whether their private insurance coverage is out-of-network. The act does not cover individuals with public insurance. The reason is to prevent surprise billing, or unexpected balance billing, where an out-of-network patient is surprised by a bill to cover the cost of care by an out-of-network provider that insurance does not cover.

“We started going through all of our patients, and we’ve determined, OK, which patients of ours do we have a contract with and which ones we don’t. And we noticed that, that Aetna Medicare Advantage plan, we did not have a contract with,” Sczygelski explained.

He said Aspirus now has a protocol in place for surprise billing, which is to contact the patient, let the know their insurance coverage is out-of-network, and discuss their options. Those options are either switching to a different insurance company or paying out of pocket for any future care at Aspirus. Again, patients told 7 Investigates, they were not notified or if they were notified that they were out-of-network, they did not believe it because they did not understand why since they were covered for the first half of the year.

“In actuality, we continue to see many of those patients, but we would try then, to do single-case agreements with Aetna for a short period of time.”

That means they are working on an individual, patient-by-patient basis with Aetna to ensure people under that retiree group coverage were actually covered for the rest of the year.

“As we’re working this out, we worked very hard then to get a contract with Aetna Medicare Advantage, because these patients, we found out, do not have an option to change MA plans.”

He is speaking about the inability of patients to rejoin the group plan in the future if they switched out of it to an insurance provider that was in the Aspirus network, especially living in an area with nearly no other provider options. Aspirus and Aetna settled on a contract to cover its Medicare Advantage plan for 2023 and accept those extended service area members for the rest of the year.

Aspirus has executed an agreement to participate in Aetna’s Medicare Advantage network effective 1/1/23. Aspirus has agreed to accept our Medicare Advantage Extended Service Area (ESA) members in the interim.

“We do need contracts. So again, it’s protecting the patient. They’re not going to get a surprise bill, and we don’t want them to, which is why we started that communication with them to begin with, which probably caused a lot of the questions that were being asked.”

For those who paid Aspirus when they otherwise would have been covered, Sczygelski stated Aspirus and Aetna are working to retroactively reimburse patients the amount they are owed based on their plan coverage. Patients do not have to contact either entity to be reimbursed, though said patients certainly can if they feel they are due something and it is not being handled correctly.

Network Health

Amidst searching for answers related to the issues Antigo Aetna members were facing, patients with a different set of circumstances and insurance began sharing their own set of concerns about Aspirus access. In early October, some patients began receiving letters from Network Health.

More letters trickled into mailboxes as the month went on and word spread as Network Health members chatted in their friend groups. Many of them live in Portage County.

“I was shocked, put it that way,” Bonita ‘Bonnie’ Zblewski said. “I was just shocked. I didn’t believe it. My husband didn’t believe it. He says people are just talking, you know, but then got the letter. So, shows right there, it’s true. And I don’t know why Aspirus is doing this.”

Her letter from Network Health came Monday.

“It says, while your plan allows you flexibility in- and out-of-network providers, Aspirus has indicated they will not schedule appointments for patients with out-of-network insurance, like Network Health in 2023. And we don’t know why. But that’s what it says.”

She had not received anything from Aspirus about this and was waiting to see if they would provide some reasoning behind the decision.

Zblewski lives in Plover, just down the street from Aspirus’ clinic location. She loves her doctor, saying she listens to her and talks with her like a real person, not a number in a line of patients to see. She said she can talk to her about anything.

“I don’t want to switch my doctor. No, because it took me,” she paused to think. “When Dr. Munk quit at Ascension. It took me four years to find a doctor that I liked. I couldn’t find anybody because he was, he was a special doctor. And this one here is just like that. She’s very special.”

Nearly all of her medical care is handled by Aspirus physicians.

She also does not want to switch the insurance coverage she has had for eight years. She is a member of Network Health’s most popular Medicare Advantage plan, which provides coverage for providers who are in- and out-of-network. Zblewski said it allows her to seek the care and the providers she wants and needs.

“We don’t have no copay for prescriptions. We pay them $5 for three months, so it’s, you know, it’s a good plan. I think the most I’ve ever paid for a prescription was $16. So, and even when I went in for surgery for my kidneys, it was-- it had to (have) been like $8,000-10,000, and I think I paid $100-and-something. So, it’s a good insurance.”

In addition, she said she appreciates the customer service, with representatives she says instantly recognize her over the phone. During the height of the pandemic, they also sent things like a blanket, sanitizer, and antiseptics to encourage good health.

“I just hate to get rid of them. You know, you’ve been with them for so long, they’re almost like part of your family. You can call them up, ‘Oh, Bonnie!’ You know, it’s like, ‘Hi!’ So yeah, I’m gonna miss them.”

Maxine Hogan has similar sentiments. Her mother put her and her sisters in charge of her care and financial decisions as she continues to lose her hearing and vision.

She has been covered under the same Network Health plan as Zblewski for several years but has lived in the Stevens Point area for even longer.

“Since 1936. She was born at St. Michael’s Hospital,” Hogan smiled. Her mother has kept the same team of providers (and their replacements as some retire) ever since.

“Aspirus does have her primary care which, of course, Aspirus and then Ascension before that, and Ministry Health before that, and Rice Clinic before that.”

Aspirus has a large presence in Portage County as it has acquired facilities, with Marshfield Clinic making up the other portion of providers available. Hogan’s mother has long-time providers now under both those systems. She said those relationships allow for more efficient visits because the doctor already knows her history. She also feels comfortable opening up about topics she may otherwise not feel comfortable sharing.

“She (her mother’s primary care provider) knows what will push mom’s buttons to get her moving in the right direction. I don’t want to lose her,” Hogan explained referring to the provider and her mother. “Because that’s, you know, at the age of 85, getting those buttons pushed is the most important thing. It’s like, ‘yes, she’s moving in the right direction.’ She’s going to have a better quality of life.”

They have also been really happy with her insurance coverage, though, especially this year after experiencing significant health issues.

“Trying to start over again would be probably a monumental issue,” Hogan stated. “The vision problem, the hearing problem, she has a really difficult time communicating, and has to have someone with her in order to make sure that the appropriate care is provided. So luckily, her current provider, you know, knows her well enough that that’s not very difficult, but if we had to switch again, that would be hard. It would be very hard for her. So, unfortunately, we have to consider just the same thing as so many of the other Network Health care, customers and consider moving.”

Hogan learned about the news related to insurance coverage next year, not through letters, but through her coworker at the ADRC of Portage County, elder benefits specialist Maria Meyer.

While Meyer is always booked with appointments to help people during the Medicare Open Enrollment season, to say this year is different is an understatement.

“Monday, I had to ask for additional assistance to make phone calls,” she said. “By the end of the day on Monday, I’ve received 96 phone calls on network health. Yesterday (Tuesday) was a little bit slower; we were down to about 70. So you know, and then today, we’ve still had more and it is the third day of the Medicare Open Enrollment. People are still finding out about this. I had a few voicemails this morning (from) people saying I didn’t get any letter. I didn’t know this was happening.”

She had heard from some people who had received letters from Aspirus too. One Network Health member in Stevens Point, who did not want to be identified, shared that letter from Aspirus with 7 Investigates.

Meyer said people have been confused, as the letter said Aspirus would not be scheduling appointments into next year for patients who did not have in-network coverage. Some patients told her that some of their appointments have been canceled if they already had it scheduled past Jan. 1, 2023.

The letter states concern about out-of-network patients having to pay unexpected expenses. It also tells patients what they can do if they want to keep receiving care through Aspirus.

Meyer shared the interpretation patients have expressed to her.

“‘Hey, we’re not going to schedule you anymore. You have an option during open enrollment, you need to switch health insurance plans, like the Aspirus Plan.’ It’s the only one that’s mentioned. So, it leads people to believe ‘my only option to maintain my doctors is to go with this Aspirus coverage,’ when in fact, they contract with several of the other advantage plans.”

Sczygelski told 7 Investigates in an interview that they did not tell patients to consider Aspirus Health Plan above any other plan.

“We are not trying to do this, in order to just steer patients to Aspirus Health Plan. What we are trying to do though, is make sure those patients understand whether they’re in network or out of network so there’s no surprise bill down the road.”

Meyer was not told that when she reached out to Network Health and Aspirus. She got the same messages the letters stated, but no explanation as for the change.

Her primary duty during this time of the year is to help seniors navigate the Medicare system, and weigh their options with the care they need, the providers they want, the prescriptions they have, and the coverage they can afford. She said that is a very individualized process that can lead many people to very different plans and insurance providers.

“For some people, the reason Network Health has been so amazing is they truly have a great package when it comes to health care benefits and medication coverage. There are some times when people look at two different plans and both of them offer really great health insurance, but one will have their medication costs thousands of dollars more than what Network Health was. So, to be able to afford both for people on limited incomes, it’s very important to have those options.”

With this news, Meyer is still carrying out her duties to work with her clients to determine the best Medicare option for them. Since patient-provider relationships often weigh heavy, especially as people get older, for many clients, she said, that best option likely means turning to different insurance rather than different doctors.

“They have two choices get new health coverage, so they can maintain their doctors or get new doctors, which is difficult in this area when Aspirus is one of the main providers.”

The leaders respond

Network Health is a provider-owned health insurance company, providing private and public coverage for patients in Wisconsin for 40 years. It is owned by Ascension Wisconsin and Froedtert Health System.

Under Network Health’s plan coverage, including the popular Medicare Advantage plan patients have talked about, Ascension providers and facilities were in-network. Aspirus was not.

At the beginning of 2022, Aspirus agreed to the terms of the Network Health plans for the rest of the year as it fully acquired some Ascension locations. The goal was not to disrupt patient care mid-year.

In a February call between Sczygelski and Network Health president and CEO, Coreen Dicus-Johnson, the two talked about their organizations’ future relationship going into 2023.

Behind the negotiations

While both organizations say they have patients’ interests in mind during negotiations, in the simplest terms, insurance companies and medical providers still have competing financial goals: one wants to pay as little as possible and the other wants to get paid as much as possible. 7 Investigates asked both leaders to explain how they handle those negotiations, in particular when determining whether to develop a network contract.

Dicus-Johnson said as someone who once was on the provider side of negotiations and who represents a company owned by providers, she understands that dynamic. She said her approach is collaborative.

“We have products and our contracts with our with our providers that allow for them to get more when we do better,” she explained. “So as they provide high quality care, if they help us manage costs, they actually get to share in that we have gained sharing basically as part of our value-based contracting.”

She said they work with providers when designing their insurance plans to encourage patients to make appointments and try to work quickly to rectify any mistakes made in claim processing.

Sczygelski explained each year they review the contracts they have with their insurance companies to determine which contracts are ending, which ones need renewing, and which ones need to be negotiated to be improved. He said not every contract needs to change every year, but every year about a quarter to a third of their contracts go through some negotiation.

“We look at whether the terms are fair. And that would have to do with the customer service aspects of it, how they’re treating the patient, we don’t want to put the patient in the middle if we can help it. And whether the reimbursement or the economics of the deal are appropriate and fair,” he said.

What he stated was fair in terms of reimbursement is “when everyone knows the rules upfront.”

“So we know what their medical policies are. You know whether those policies are going to change or how they’re going to change. You know how they’re going to reimburse, and at what level they’re going to reimburse so we can determine OK, is it fair? Is it covering our costs? Do we make any margin out or don’t we?”

He added rules like requiring preauthorization for certain care can also impact their end of the deal, saying that can cost them more. Paying on time matters too for the well-being and fair treatment of not only their bottom line but the patient too.

“For example, if you’re not paying the claim timely and you’re an insurance company, at some point, we start billing the patient. The patient doesn’t want to see those statements, they don’t want to have that anxiety that, ‘hey, my bill might not be paid.’”

He continued, one example of that is Anthem Blue Cross Blue Shield. Sczygelski said the contract was signed in 2017 and had not been renewed for a long time. They began negotiations with them in June in order to update the contract to reflect the economic times fairly.

“Because that contract rolled over for so many years, aspects of that contract were literally unfair to us in terms of the reimbursement that we were receiving, because inflation had gone on and on and on. Cost increases have gone up, and in some cases, our reimbursement has been flat for that period of time.”

Anthem confirmed the contract was signed in 2017, but told 7 Investigates that the reimbursement has not been “flat.” A spokesperson said the contract allows for increasing rates every year and that Aspirus’ increase was similar to other hospital groups.

He said they also noticed the company’s denial rate of claims was “extraordinarily high,” adding that they are a slow payer too.

“Those were some of the issues that we wanted to talk to them about. So, we went into negotiation with them in good faith. We got to the point, though, where we thought, we’re not going to get a good contract here unless we terminate the existing contract so it doesn’t auto-renewal. So, we terminated the contract and we’ve been in negotiations since. We think we’re making some progress, but there’s a lot more progress to make.”

Anthem told 7 Investigates as it pertains to denials that it has a responsibility to ensure that claims are billed and paid appropriately. The spokesperson explained the reason a claim may get denied at first could be due to a coding error on the part of the provider, or that Anthem does not believe it has enough information for a claim. These issues can cause payment of these claims to be delayed.

The spokesperson said Anthem is working with Aspirus to create efficiencies toward accurate billing and paying in a reasonable time. The contract does designate timelines for each of the various procedures and billable care, which guides what is a reasonable expectation of payment for each claim.

Anthem also sent a full statement in response to 7 Investigates’ questions and Aspirus’ response:

While Aspirus terminated its contract with Anthem Blue Cross and Blue Shield, we continue to negotiate a new contract so that we can maintain access to affordable care for those we serve and for those who are most in need. We remain concerned that Aspirus is refusing to accept Anthem Medicaid and Medicare members as part of a new agreement. This would severely limit access to care for many of the most vulnerable in those communities, and eliminate the critical checks and balances on cost and quality Anthem provides for its members. Additionally, Aspirus is demanding double-digit price increases over the next two years for individuals and people covered through their employer, putting further financial pressure on people and businesses. We will continue to work with Aspirus to reach a favorable outcome, which means protecting access and affordability for all of those we serve.

Sczygelski said since terminating the contract, they have been informing employers and insurance brokers that they may not have a contract by Jan. 1, 2023, so as not to mislead those looking to sign onto that coverage thinking Aspirus will be in-network.

“So if they had, for example, an Anthem Medicare Advantage or an Anthem commercial product, thinking that come Jan. 1 or February or whatever, that they’d be able to see Aspirus providers, we want to make sure that they knew that that’s not necessarily the case. We may not get a contract finalized, but our intent is that we will be able to do that.”

Discussions of Aspirus and Network Health’s future together, or not

Returning to that February call between the two organizations, Dicus-Johnson said they wanted to contract with Aspirus and offered them to become a part of their value-based contracting.

“They refused to negotiate,” she said.

Sczygelski told 7 Investigates he had several reasons for not wanting to contract with Network Health. He said Network Health is a small insurance provider.

“There are three, four or five different ma plans Medicare Advantage plans that are larger than them in our market. And we can’t and don’t want to contract with everybody.”

“We disagree with Aspirus’ characterization that our plan is so small,” Dicus-Johnson said in a follow-up email related to Sczygelski’s responses. “As of the September CMS membership reports, Medicare Advantage membership in the Aspirus service area shows we are the second largest carrier with over 10,000 members. United Healthcare has 11,800 members and the Aspirus MA plan has 458 members. Additionally, the other options are not of the same caliber, we are the only 5-STAR Medicare Advantage Plan in Portage County for 2023.”

Sczygelski said he also had concerns that they did not meet what is called “network adequacy.” It is a Centers for Medicare & Medicaid Services rule that requires insurance providers to show proof that their Medicare Advantage plan members have sufficient access to a particular set of in-network provider services to meet their needs. The reason for the rule is to help patients avoid surprise billing or balance billing.

“I informed him on the call that we would meet the standards because we had entered into some new agreements,” Dicus-Johnson noted. “We advised CMS that Aspirus would be out of network and they have no issues with our network adequacy.”

7 Investigates reached out to CMS to confirm whether Network Health meets network adequacy in the Aspirus service area without contracting with Aspirus. CMS is working on a response.

Due to that concern, Sczygelski said he offered to “acquire the lives” of Network Health plan members in the Aspirus service area, meaning to essentially come to a deal to move the members from Network Health’s plan to Aspirus’ health plan. He gave an example of this scenario when the Aspirus Health Plan was formed about four or five years ago and they worked with WPS to acquire its lives to their plan.

“We did that through soft mechanisms, working with brokers and so forth, working with employers and so forth and saying, ‘Hey, this is the benefits you had. This was the care you were provided. This is the network. Here it is here, very similar, and yes, you’ve got the option to go wherever you want, and that’s, that’s fair. It’s a market-based system, but we would like to continue the relationship if we could.’ And we then work with them on that and there was an incentive that we paid to WPS as we converted those lives over.”

“I further explained that I could not just sell him the lives, this membership was part of our overall contract with CMS, and the only transaction that could facilitate this would be a sale of Network Health,” Dicus-Johnson stated in response to his comment over email. “This was not an offer I was willing to put on the table.”

“We said fine, that’s acceptable to us. And so we just ended it there,” Sczygelski stated.

“We didn’t really think that it would be an issue because quite frankly, our members have been able to always go there (to Aspirus), and we’ve paid the same Medicare rate,” Dicus-Johnson commented about not contracting. “And so, this was not something that was raised as an issue for us.”

Patients stuck in the middle between a difference in legal interpretation

Aspirus’ and Network Health’s perspectives on whether Network Health’s Medicare Advantage plan that provides coverage for patients to see providers in- or out-of-network fully covers patients’ bills is a conflict that is leaving patients with uncertainty.

“What’s unique about Medicare is that the rate that we pay is the same whether you’re in-network or out-of-network, so they are not-- Aspirus would not be receiving reimbursement any differently if they were in-network or out-of-network,” Dicus-Johnson stated.

“They can say, ‘Yes, we will pay that provider whether they’re in-network or not at the Medicare rates,’ but we don’t have to accept that. And nobody has to accept that,” Sczygelski stated. He, again, cited surprise billing as a concern and referred to the federal regulation related to that.

Dicus-Johnson said balance billing a patient with this coverage would be “inappropriate.” She referred to the requirements of Medicare Provider Participants.

“Meaning that if they’re taking Medicare, the Medicare rate that we pay is the payment in full,” she said, adding with the exception of deductible, coinsurance, and copayment due under Medicare Part B, Medicare Advantage, or Med Supplement plan.

As the organizations dispute, patients are left weighing their risks and options. For many patients on fixed incomes who spoke with 7 Investigates, there does feel like there is much choice.

“What are you going to do? Are you gonna switch from Network and get a different one,” 7 Investigates asked Zblewski.

“I kind of have to because I sure couldn’t pay every time I go in.”

Dicus-Johnson replied, “Yes” when asked whether patients who remain on their plan with in- and out-of-network coverage would still be fully covered if they seek care with Aspirus in 2023.

“We stand ready, willing, and able if they wanted to reconsider a contract with us,” she added. “We want to make sure that our members have good choices of health care, and we would, we would welcome that opportunity. That being said, if that’s not something that they wanted to do, we appreciate that, you know, that’s their decision. We just want them to continue to take care of their patients.”

Sczygelski said they are not interested in contracting with Network Health at this time. As for the patients who really love both their provider and insurance, he said the intent is in the interests of patients.

“We do not want to put the patient in the middle, and we’re not going to do that. So, we would recommend to the patient, make sure you have an insurance product that’s comprehensive and covers what you need covered. And make sure that the providers you want to see are in that plan.”

7 Investigates has asked CMS what the correct legal interpretation is of these out-of-network coverage plans and provider billing rights. 7 Investigates received answers to those questions the week following this publication. See those answers here.

This story has been updated since first being published to reflect new developments.

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