7 Investigates: Aspirus and Anthem in active negotiations to come to contract agreement

7 Investigates
Published: Oct. 26, 2022 at 7:46 PM CDT
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(WSAW) - Anthem Blue Cross Blue Shield and Aspirus are in active negotiations, with both organizations saying they are hoping to come to an agreement to become part of each other’s health network. However, patients are getting confused.

Anthem members around north central Wisconsin shared letters they received with 7 Investigates from Aspirus. It informs patients that Aspirus could be an out-of-network care provider for Anthem members next year.

Aspirus sent letters to patients of theirs who had Anthem as insurance. It informs patients...
Aspirus sent letters to patients of theirs who had Anthem as insurance. It informs patients that Aspirus could be out-of-network with Anthem's coverage next year. 7 Investigates redacted the letter to protect patient privacy.(WSAW)

Patients told 7 Investigates they are frustrated, especially if it is an employer-provided insurance coverage and Aspirus is either one of two or the only provider depending on the local area in north central Wisconsin region.

Sid Sczygelski, Aspirus’ Senior Vice President of Finance and Chief Financial Officer said 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.”

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.’”

Sczygelski said they had some of those concerns with Anthem Blue Cross Blue Shield.

The contract was signed in 2017 and had not been renewed since. 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.

Sczygelski 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.

Anthem Spokesperson

This is not the only insurance company Aspirus is making changes to its agreements. 7 Investigates heard from patients under other insurance coverage receiving similar letters of notice of out-of-network. See the report here.