Anthem BCBS in New York and New York City-based Mount Sinai Health System have been entrenched in a heated contract dispute, with physicians and facilities going out of network at the beginning of the year and in March, respectively.
Becker’s spoke with Victor DeStefano, commercial president for Anthem BCBS in New York, and Brent Estes, senior vice president and chief managed care and population health officer for New York City-based Mount Sinai Health System.
The negotiations consist of “constant communication,” according to Mr. DeStefano. Mr. Estes said he now feels “numb” toward the process. In a previous interview with Becker’s, Mr. Estes had said he is unsure of where the 200,000 Anthem commercial members who Mount Sinai sees each year will go for care.
Here are the seven parts of the contract that are still under discussion — and where each party stands.
Rates (sort of)
Mr. DeStefano said price increases and major financial points have already been agreed upon.
Mr. Estes said that, while the organizations settled on an annual reimbursement trend for three consecutive years, that hinges on whether Anthem addresses the negotiation’s other issues. He also noted that some services and locations do not have concrete rate agreements yet, which will be a continued discussion if the organizations sign an initial contract.
Billing accuracy and audit rights
Mr. DeStefano said Anthem’s medical necessity and appeals process abides by clinical standards, and the insurer is pushing for itemized bill review. He further said certain claims in the “hundreds of thousands” may not be subject to review under Mount Sinai’s proposal.
Mount Sinai found “a lot of those reviews are completely unnecessary,” Mr. Estes said, adding Anthem often pays for these claims without adjustments. He said Mount Sinai’s revenue cycle process is pushed out further amid these reviews.
“These are what we consider to be high-volume, no-value audits that clients are paying for in their administrative service fees, and they’re getting nothing in return for them,” he said. Mr. Estes said Mount Sinai is instead advocating for one-time information requests.
He also said Anthem agreed to raise the review threshold for “high-dollar claims” from $50,000, but an exact number has not been set yet.
Claim submission timing
Mr. DeStefano said 94% of Anthem New York members come from self-funded plans with employers covering claims. As a fiduciary, Anthem strives for employers to have some level of predictability with their healthcare spend. Mr. DeStefano said Mount Sinai wants to change timely filing limits.
Mr. Estes said the idea that Mount Sinai is seeking unlimited time to submit claims is “patently false.”
Termination rights
Mr. DeStefano expressed concerns over allowing Mount Sinai to terminate the contract at will.
“There wouldn’t be stability for the families that have Anthem, the employers that have Anthem,” he said.
However, Mr. Estes said Anthem initially brought up this point, reaffirming the offer as recently as late February. He said Anthem has since backtracked on this.
“The reason that they offered that to us, and we accepted it, was because of the fact that we were not confident that they would be able to execute on the promises that they made,” Mr. Estes said.
Anthem said this is “categorically false,” claiming Mount Sinai initiated the most recent contract’s termination. The insurer also said the health system maintains a termination with cause provision already, granting a safety net for both sides of the equation.
Payment processing speed
Mr. Estes said the Blues structuring can prolong the timing for payment processing. For example, if a BCBS Texas member who lives in New York files a claim, that claim is routed to Anthem, then to BCBS Texas for adjudication and then back to Anthem in New York. He said the other insurers Mount Sinai works with can pay claims in 30 days.
Anthem said payment timelines in the Mount Sinai agreements have not changed in 20 years and acknowledged the 30-day turnaround time.
Outstanding payments
Mr. Estes and a recent Mount Sinai statement both claim Anthem owes the health system for services already provided. The statement said these claims total in the “hundreds of millions of dollars.”
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