7 Investigation: Aspirus and Network Health disagree on Medicare rules, CMS clarifies

7 Investigation: Aspirus and Network Health disagree on 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 over the legal interpretation of some Medicare rules.

Last week, 7 investigators shared that some patients had received letters from either only Network Health, Aspirus, or both, stating that Aspirus would not be a network provider for 2023.

“I was shocked, to put it that way,” said Bonita ‘Bonnie’ Zblewski, an Aspirus patient and Network member. “I was just shocked. I didn’t believe it. My husband didn’t believe it. He says people just talk, you know, but then he got the letter. So just show there, c 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 finance, Sid Sczygelski, said he was not interested in contracting with the insurance company. One of the reasons Sczygelski cited was that they didn’t follow what’s called “network adequacy.”

This is a Centers for Medicare & Medicaid Services (CMS) rule that requires insurance providers to prove that members of their Medicare Advantage plan have sufficient access to a particular set of in-network provider services to meet their needs. The reason for this rule is to help patients avoid surprise billing or balanced billing.

“I informed him on the call that we would be meeting the standards because we had new agreements,” said Coreen Dicus-Johnson, president and CEO of Network Health. “We have informed CMS that Aspirus will be off-grid and they have no issues with our network adequacy.”

This is just one of two other items that 7 investigators have asked CMS to clarify, as Aspirus and Network Health have come to different understandings of particular Medicare rules.

Network adequacy

7 Investigators have contacted CMS to confirm whether Network Health meets network adequacy in the Aspirus service area without contracting with Aspirus.

“Network Health met the CMS Network adequacy requirements when its network was reviewed in June 2022. CMS reviews planned networks every three years and retains the right to review a network at any time,” a carrier replied. word of CMS.

Network Health further clarified that the June review included Aspirus as part of the 2022 network. However, in September, Network Health informed CMS that there would be a change for 2023, with Aspirus no longer in the network. Network Health said CMS told them they still met the network adequacy requirement. 7 Investigators have again contacted CMS to confirm and CMS is working on a response.

law without surprise

Sczygelski also referred to federal regulations in effect at the start of 2022, which caused Aspirus to review insurance coverage for its patients. The No Surprises Act places more requirements on providers and insurance companies to notify patients if their coverage is out of network. The reason is to avoid surprise billing, or unexpected balance billing, when an out-of-network patient is surprised with a bill covering the cost of care from an out-of-network provider that insurance does not cover.

“Usually, surprise medical bills are bills that patients receive when they visit a provider that is not part of their health insurance network,” said Rachel Cissne Carabell, assistant commissioner for the Wisconsin Office of the Commissioner of Insurance. “Often we think of surprise medical bills when that patient didn’t know that that provider was out of network or had no choice, for example, in an emergency situation.”

She said there are basically three types of services for which providers and insurance companies cannot charge the patient for care they receive from an out-of-network provider: emergency services, emergency services, air ambulance and some non-emergency services. For the first two, patients generally have no choice but to go to an in-network provider or may not know if a provider is in-network along the way.

The third situation also comes into play when the patient would probably not know that he was seeing an out-of-network provider.

“You may be going to have surgery or you may have to have some tests,” Cissne Carabell posed. “And while the facility may be networked, some of the providers providing services to you may not be and you may not even see them, for example, an anesthetist, a radiologist looking at an x-ray or an MRI .”

For non-emergency scenarios or when the patient is stable and conscious after an emergency, providers have a responsibility to inform the patient before they receive services or attend appointments that they are receiving emergency care. a service provider who is not covered by his insurance. network. The patient must consent to receive these services. If the provider does not ask for consent in advance, they cannot charge the patient for costs that the insurance will not cover.

“If the provider and the insurer disagree on the amount to be paid, the insurer and the provider must follow a separate process to determine the amount to be paid,” explained Cissne Carabell. “But the patient is kept out of this disagreement.”

This federal change to surprise billing is part of the reason Sczygelski said he sent letters to all patients they identified as having insurance that Aspirus did not have a contract with for 2023, including patients benefiting from Medicare Advantage plans.

“We don’t want to put the patient in the middle, and we’re not going to,” he said. “So we recommend the patient to make sure they have an insurance product that is comprehensive and covers what you need. And make sure the vendors you want to see are in that plan. »

However, CMS confirmed what Network Health had asserted: that the law “does not apply to providers or establishments in connection with the provision of items or services to beneficiaries or enrollees in federal programs such as Medicare ( including Medicare Advantage), Medicaid (including Medicaid Care Plans), Veterans Health Care, Indian Health Service or TRICARE These programs already have other protections in place to deal with high medical bills.

CMS also referenced two documents answering frequently asked questions, including for the implementation of the law without surprises and for suppliers.

Medicare Advantage Patient Balance Billing

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

Aspirus and Network Health’s views on whether Network Health’s most popular Medicare Advantage plan covers patients as advertised is a dispute that leaves patients uncertain. This plan provides coverage for patients to see providers in or out of the network. Dicus-Johnson said it fully covers patient service bills at any provider that accepts Medicare, with the patient paying only for items in the coverage plan, such as deductibles and copayments.

“What’s unique about Medicare is that the rate we pay is the same whether you’re in-network or out-of-network, so they’re not – Aspirus wouldn’t receive reimbursement any differently if they were on-grid or off-grid. off-grid,” Dicus-Johnson said.

Aspirus disagrees with this interpretation of the Medicare rules.

“They can say, ‘Yes, we’ll pay this provider, whether it’s in-network or not, at Medicare rates,’ but we don’t have to agree to that. And no one should accept that,” Sczygelski said. He, again, cited surprise billing as a concern and referenced federal regulations on this.

Dicus-Johnson said charging a patient’s balance with this coverage would be “inappropriate”. She referred to the requirements of participating health insurance providers.

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

7 Investigators contacted Aspirus for comment on CMS’s responses, but CMS did not respond. 7 The surveys also informed Network Health of CMS’s responses. He responded with this comment:

“Network Health offers affordable Medicare Advantage plans that give our members the freedom to choose their doctors and hospitals. Unfortunately, it is clear from Aspirus’ words and actions that they are trying to limit this freedom. CMS has confirmed that the reasons given by Aspirus for its actions are not valid. We urge Aspirus to reconsider its decision to deny care to people who choose a Network Health Medicare Advantage plan.

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