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 at a loss as two organizations disagree over the legal interpretation of certain Medicare rules. increase.

Last week, 7 Investigates revealed that some patients had received letters from Network Health, Aspirus, or both, stating that Aspirus would not be an in-network provider in 2023.

“I was shocked, come to think of it,” said Aspirus patient and Network member Bonita ‘Bonnie’ Zblewski. “It was just a shock. I didn’t believe it. It’s shown, it’s true, I don’t understand why Aspirus is doing this.”

Aspirus doesn’t need to sign with Network Health, and chief financial officer and senior vice president of finance Sid Sczygelski said he’s not interested in signing with insurance companies. One of the reasons Sczygelski gave, he said, was the concern that the so-called “network validity” was not being met.

This is a Medicare and Medicaid Services (CMS) rule that requires insurance providers to certify that Medicare Advantage Plan members have sufficient access to a specific set of in-network provider services. The reason for this rule is to help patients avoid unexpected charges and differential charges.

Network Health President and CEO Coreen Dicus-Johnson said: “We have told his CMS that Aspirus will be off the network and they have no problem with the validity of our network.”

This is just one of two other factors. 7 Investigates asked CMS for clarification. Aspirus and Network Health have reached different understandings of certain Medicare regulations.

network adequacy

7 The team contacted CMS to confirm whether Network Health met network suitability in the Aspirus service area without contracting with Aspirus.

“Network Health met the CMS network adequacy requirements when the network was reviewed in June 2022. CMS will review the network plan every three years and reserves the right to review the network at any time. Yes,” a CMS spokesperson replied.

Network Health also revealed in its June review that it included Aspirus as part of its 2022 network. However, in September, Network Health informed CMS that there will be changes in 2023 and Aspirus will no longer be in the network. According to Network Health, CMS said it still meets network adequacy requirements. 7 The investigation contacted CMS again for confirmation and CMS is working on a response.

no surprise method

Sczygelski also spoke about federal regulations that take effect in early 2022. As a result, Aspirus has reviewed patient insurance coverage. The No Surprises Act imposes more requirements on health care providers and insurance companies to notify patients if their coverage is out of network. The reason for this is to prevent out-of-network patients being surprised by bills covering treatment costs by out-of-network providers that their insurance does not cover, resulting in sudden charges, or unexpected balance charges.

“Surprise medical bills are typically bills that patients receive when they go to a provider who is not part of their health insurance plan network,” said Wisconsin Acting Commissioner of Health Rachel Sisne Carrabell. “Often, we think about sudden medical bills when patients didn’t know that their provider wasn’t on the network, or that they had no choice, such as in an emergency.”

She said there are basically three types of services that providers and insurers cannot charge patients for care provided by providers outside their network. These are emergency services, air ambulance services, and some non-emergency services. In her first two cases, the patient usually cannot choose whether to go to an in-network provider or may not know if a provider is in-network on the way.

A third situation also occurs when the patient is likely unaware that they are meeting with an out-of-network provider.

“Maybe I need to have surgery or some tests,” Cisne Caravelle posed. “The facility may be in the network, but it may not be among the providers servicing you. Etc.”

For non-emergency scenarios, or if the patient is stable and conscious after an emergency, the healthcare provider is responsible for notifying the patient prior to receiving services. Communication network. Patients must consent to receive these services. Patients cannot be billed for charges not covered by insurance unless the provider seeks prior consent.

“If there is a disagreement about how much the provider and the insurance company should pay, we have to go through a different process to determine what the insurance company and the provider should pay,” explains Cissne Carabell. “But patients are shielded from that disagreement.”

This federal change to surprise billing has sent letters to all patients Aspirus has identified as having non-contractual insurance in 2023, including those on Medicare Advantage plans, Sczygelski said. That’s part of the reason.

“We don’t want to put the patient in the middle, nor will we,” he said. “That is why we recommend that patients make sure they have an insurance product that is comprehensive and covers what they need. And make sure the provider they want to see is included in that plan .”

However, CMS confirmed what Network Health claimed. This law applies to “providers or facilities involved in providing items or services to beneficiaries or enrollees of federal programs such as Medicare (including Medicare Advantage) and Medicaid (including Medicaid-administered programs). Care Plan), Veterans Affairs Health Care, Indian Health Service, or TRICARE.These programs already have other protections in place to deal with high medical costs.”

CMS also consulted two documents that answer frequently asked questions, including those for No Surprises Act implementers and providers.

Balance Billing Medicare Advantage Patients

If a patient’s insurance only covers services with in-network providers, those patients may pay more to go to a provider who doesn’t have an insurance company. However, for Medicare Advantage plans, Network Health’s most popular preferred provider organization, patients are told they don’t have to worry about that.

Aspirus and Network Health’s views on whether Network Health’s most popular Medicare Advantage plan will cover patients as advertised leaves patients uncertain. This plan provides coverage for patients to see in-network or out-of-network providers. Dicus-Johnson said it fully covers patient service claims for all providers that accept Medicare, and patients pay only what’s stated in their coverage plan, including deductibles and copayments. .

“What is unique about Medicare is that we pay the same rate whether you are in-network or out-of-network. You don’t get it, you’re out of network,” said Dicus-Johnson.

Aspirus disagrees with its interpretation of the Medicare regulations.

“They can say, ‘Yes, I’ll pay that provider at Medicare rates, whether they’re in the network or not,’ but they don’t have to accept it. And no one has to accept it.” No,” said Sczygelski.

Dicus-Johnson said the balance billed to patients for this coverage was “inappropriate.” She mentioned requirements for Medicare provider participants.

CMS confirmed Dicus-Johnson’s interpretation. Out-of-network Medicare participating providers said they were not allowed to bill Medicare Advantage program participants for plan-covered services. and quoted Title 42 of the Code of Federal Regulations.

7 The team contacted Aspirus for comment on CMS’ response, but did not receive a response. 7 The survey also informed Network Health of CMS’ responses. It was answered with this comment:

“Network Health offers an affordable Medicare Advantage Plan that gives members the freedom to choose their doctors and hospitals. CMS has confirmed that the reasons for action presented by Aspirus are not valid and encourages Aspirus to reconsider its decision to deny care to individuals who have opted for the Network Health Medicare Advantage plan. ”

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