An Illinois man is facing thousands of dollars in cancer treatment bills from Blue Cross Blue Shield of Illinois after his Springfield Clinic oncologist went out of network following a terminated contract between the payer and provider last year, WCIA reported May 31.
Jim Whaley and his wife Sharon were recently told that he was cancer-free at HSHS St. John's Hospital in Springfield, Ill.
Eight months after his initial diagnosis, the Whaleys say they are now facing huge medical bills from Blue Cross Blue Shield of Illinois. The couple are enrolled in a group plan through Mr. Whaley's union, the National Electrical Contractors Association (NECA-IBEW).
Mr. Whaley's radiation oncologist at Springfield Clinic went out of network in November after he was diagnosed and was getting ready for treatment. Every radiation oncologist in the Illinois capital was pushed out-of-network following a contract dispute with BCBSIL over reimbursement rates, forcing the Whaleys and other patients to choose between receiving care and high medical bills.
Ms. Whaley said charges from BCBS now range from $40 to $52,000, and the cost of the treatments now exceeds the $3,800 out-of-pocket maximum written on Mr. Whaley's member ID card.
"Every time you call Blue Cross, it's, 'What you owe is what you owe, we don't have anything to say about it,'" Ms. Whaley told WCIA.
"I don't think it's fair for the insurance company to ask you to go see a radiologist in Chicago," Mr. Whaley told WCIA. His radiation treatments would have been a daily three-hour commute from Springfield, and he still has follow-up appointments every other month. Though unions are able to opt in to benefits like continuity of care in the face of a payer-provider contract termination, the Whaleys' union does not offer it.
The No Surprises Act does require unions to include continuity of care provisions in plans after Jan. 1 of this year, but Mr. Whaley's oncologist was already out of network by the time of that requirement.
Mr. Whaley's bills issued after Jan. 1 should be covered at an in-network rate, but the deadline for payers and providers to meet that requirement is unclear, according to WCIA.
The union spokesperson told WCIA they would be in compliance with the new requirement but did not provide a date.
In March, the Whaleys appealed the medical bills to BCBS and the Labor Department, which regulates union-sponsored group health plans. The Whaleys also appealed to the union.
A BCBSIL spokesperson told WCIA that in the case of "plans that are funded and administered by employers, labor unions and other organizations … member claims and appeals are not reviewed by BCBSIL."
A Labor Department spokesperson told WCIA that reviewing the appeal was the union's responsibility.
"Under ERISA, group health plans must run a process for the review of claims decisions that meets regulatory requirements for a full and fair review process," the spokesperson said in an email. They added, "As part of those ACA requirements, plans and issuers must also provide external review for adverse benefit determinations. In many circumstances, this means that the review must be conducted by an independent review organization."
It's unknown whether the union has begun to review the appeal, and the union's lawyer declined to comment to WCIA.
"It's low on the list right now," Ms. Whaley told WCIA. "So they may not get to it until October. We have no answers."
Representatives with Springfield Clinic told WCIA they won't bill the Whaleys while the appeal process is ongoing and said they are still in negotiations for a new contract with BCBSIL.
"Springfield Clinic was hopeful that new leadership at Blue Cross would bring a more collaborative approach to negotiations. Unfortunately, BCBSIL's latest proposal is a significant move in the wrong direction on a potential compromise," a spokesperson told WCIA.
"Blue Cross and Blue Shield of Illinois has been working with Springfield Clinic for nearly a year to reach a deal that ensures our members have access to the quality care they need at affordable prices. We proposed an arrangement to the Clinic that would deliver quality and value for our customers and members but, to date, the Clinic has not shown interest in such an arrangement," a spokesperson told WCIA.