7 Investigates: Aspirus and Network Health disagree about Medicare rules, CMS clarifies

(WSAW) - Aspirus patients with Network Health Medicare Advantage plans that cover out-of-network providers are in limbo as the two organizations disagree about the legal interpretation of certain Medicare rules.

Last week, 7 Investigates shared some patients had been receiving letters either just from Network Health, Aspirus, or both stating that Aspirus would not be an in-network provider for 2023.

“I was shocked, put it that way,” Bonita ‘Bonnie’ Zblewski, an Aspirus patient and Network member 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.”

Aspirus does not have to contract with Network Health, and its chief financial officer and senior vice president of finances, Sid Sczygelski said they are not interested in contracting with the insurance company. One of the reasons Sczygelski cited was a concern that they did not meet what is called “network adequacy.”

It is a Centers for Medicare & Medicaid Services (CMS) 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,” Network Health president and CEO, Coreen Dicus-Johnson noted. “We advised CMS that Aspirus would be out of network and they have no issues with our network adequacy.”

That is just one of two other elements 7 Investigates asked CMS to clarify, as Aspirus and Network Health came to different understandings of particular Medicare rules.

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.

“Network Health was meeting CMS network adequacy requirements when their network was reviewed in June, 2022. CMS reviews plan networks every three years and maintains the right to review a network at any time,” a CMS spokesperson responded.

Network Health further clarified that the review in June included Aspirus as part of the 2022 network. However, in September, Network Health notified CMS that there would be a change for 2023, with Aspirus no longer being in-network. Insurers need to validate their network adequacy for their health plans prior to submitting the change to CMS, which Network Health did. Network Health said CMS told them they still met the requirement for network adequacy. 7 Investigates reached out again to CMS to confirm and CMS is working on a response.

No Surprises Act

Sczygelski also talked about federal regulations that into effect at the beginning of 2022, which caused Aspirus to review their patients’ insurance coverage. The No Surprises Act puts more requirements on providers and insurance companies to inform patients whether their coverage is out-of-network. 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.

“Usually, surprise medical bills are bills that patients get when they went to a provider that is not in their health insurance plans network,” Rachel Cissne Carabell, Wisconsin Office of the Commissioner of Insurance’s deputy commissioner said. “Oftentimes, we think of surprise medical bills when that patient didn’t know that that provider wasn’t in-network or they didn’t have a choice, for example, in an emergency situation.”

She said there are basically three types of services where providers and insurance companies cannot bill the patient for the care they are given by an out-of-network provider: emergency services, air ambulance services, and some non-emergency services. For the first two, patients typically do not have a choice of whether to go to an in-network provider or may not know whether a provider is in-network en route.

The third situation comes into play also when the patient would not likely know that they are seeing an out-of-network provider.

“You’re going to maybe have surgery or maybe having to have some testing done,” Cissne Carabell posed. “And while the facility might be in-network, some of the providers that provide services to you may not be and you may not even see them, for example, an anesthesiologist, a radiologist that reviews an x-ray or an MRI.”

For non-emergency scenarios or when the patient is stable and conscious after an emergency, providers have the responsibility to inform the patient before they receive services or show up to the appointment that they are receiving care from a provider that is out of their insurance’s coverage network. The patient has to consent to receive those services. If the provider does not ask for consent ahead of time, it cannot bill the patient for charges insurance will not cover.

“If the provider and the insurer get into a disagreement about how much to be paid, there is a separate process for the insurer and the provider to go through to figure out how much they should be paid,” Cissne Carabell explained. “But the patient is kept out of that disagreement.”

This federal change for surprise billing is partly why Sczygelski said they sent letters to all patients they identified as having insurance that Aspirus did not have contracts with for 2023, including patients with Medicare Advantage plans.

“We do not want to put the patient in the middle, and we’re not going to do that,” he said. “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.”

However, CMS confirmed what Network Health had been asserting: that the act “does not apply to providers or facilities in connection with furnishing items or services to beneficiaries or enrollees in federal programs such as Medicare (including Medicare Advantage), Medicaid (including Medicaid managed care plans), Veterans Affairs Health Care, the Indian Health Service, or TRICARE. These programs already have other protections in place to address high medical bills.”

CMS also referred to two documents answering frequently asked questions, including for No Surprises Act implementation, and for providers.

Balance billing Medicare Advantage patients

If a patient’s insurance only covers services with in-network providers, those patients could pay more to go to a provider not contracted with their insurance company. However, in the case of Network Health’s most popular preferred provider organization Medicare Advantage plan, patients are told they do not have to worry about that.

Aspirus’ and Network Health’s perspectives on whether Network Health’s most popular Medicare Advantage plan covers patients as advertised is a conflict that is leaving patients with uncertainty. That plan provides coverage for patients to see providers in- or out-of-network. Dicus-Johnson said it fully covers patients’ service bills at any provider who accepts Medicare, with the patient only paying for things laid out in the coverage plan, like deductibles and copays.

“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.

Aspirus does not agree with that interpretation of the Medicare rules.

“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.

CMS confirmed Dicus-Johnson’s interpretation. It said out-of-network Medicare participating providers are not allowed to balance bill Medicare Advantage program enrollees for plan-covered services. It cited section 170 of chapter 4 of the Medicare Managed Care Manual, as well as Title 42 of the Code of Federal Regulations.

7 Investigates reached out to Aspirus for comment related to CMS’ answers, but it did not respond. 7 Investigates also informed Network Health of CMS’ answers. It responded with this comment:

“Network Health offers affordable Medicare Advantage plans that provide our members with the freedom to choose their physicians and hospitals. Unfortunately, it is clear from Aspirus’s words and actions that they are trying to limit this freedom. CMS has confirmed that the reasons Aspirus has offered for its actions are not valid. We invite Aspirus to reconsider its decision to deny care to individuals who choose a Network Health Medicare Advantage plan.”

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