/Transplant candidates with Blue Cross impacted by insurance dispute

Transplant candidates with Blue Cross impacted by insurance dispute

End-stage liver disease was the only option for him. A liver transplant was his only option. He had to have a double hip replacement and a number of procedures on his stomach. Also, he saw a variety of specialists including psychologists. He began a special diet and followed all the instructions from his doctors. All of this was to be eligible for a transplant at the University of Mississippi Medical Center. This is the only state organ transplant program. He received the sad news that his liver was getting worse and he was now eligible for the transplant list in January. The liver problem isn’t linear. It is exponential. The liver problem doesn’t get worse over time. One day you’re doing well and then suddenly you have to stop. After all the waiting and work, he was now ineligible for an organ transplant. He is not alone. Blue Cross & Blue Shield Mississippi, the state’s largest insurer, removed UMMC from its network on April 1. UMMC requested higher reimbursement rates and disapproved with Blue Cross & Blue Shield of Mississippi’s quality care plan. This plan measures hospital performance and assesses whether patients receive adequate services. According to Milliman’s 2021 whitepaper, Mississippi has the lowest reimbursement rates from commercial insurance companies for inpatient care. Outpatient reimbursement rates are lower than the rest of the nation. Blue Cross refused to accept the hospital’s proposal. Tens of thousands of Mississippians had to pay more out-of-pocket costs or seek care elsewhere. UMMC is the state’s only organ donor center. It also has the only children’s hospital and Level I trauma center. According to UMMC officials, about 10% of all transplants are performed annually by children and adults with Blue Cross insurance. They are not covered by the “continuity-of-care” obligation. This requires that the hospital honor certain in-network rates for certain patients up to June 30. Officials at UMMC say that this is because a transplant patient’s care goes beyond 90 days. They also require a lifetime prescription of expensive immunosuppressant medications. When asked about the impact of the dispute on organ transplant candidates, Mike Chaney, the state commissioner for insurance, said that they are still looking into the legal issues and the authority to bring about a settlement. READ MORE: UMMC moves out of network with Blue Cross Blue Shield. The metro area was chosen by the liver transplant candidate to receive better care after a serious car accident. In 2020, he was diagnosed with liver disease and discovered that UMMC’s program was one of the top three nationally by the Scientific Registry of Transplant Recipients. He felt relieved that he could access the life-saving treatment from a trusted provider nearby. His care team advised him that the call to a liver could come at any time of day or night. He should have a bag and be within an hour of the hospital. He should monitor his health and notify his doctors immediately if there are any problems. The transplant coordinator called him the following week. He recalled, “They said, ‘Your insurance isn’t willing to pay.’” He thought they meant he was removed from the list completely, but later clarified that he was on “hold”, meaning that if his perfect organ becomes available, he would not be receiving it at UMMC. Marc Rolph, UMMC’s executive director of marketing and communications, stated that the practice of putting potential transplant recipients on hold or marking them “inactive” due to changes in insurance is not new. He said that there are situations where someone has insurance (which we accept), and they go on the transplant list. Then, they change their insurance to one not in our network. Rolph stated that UMMC will release the patient’s name if it is back in network with the insurance company. He said, “So you’re still listed, you haven’t lost your place,” A match is made through the complex database of potential donors maintained by the United Network for Organ Sharing when an organ becomes available. This rare event occurs because only a small number of people are on ventilators before their deaths. Matches are based on many factors, including blood type, medical urgency, and location of the transplant center. Patients with Blue Cross who are not on the UMMC transplant list will not be notified if a suitable organ becomes available, as long as UMMC is out of network. It would instead go to another candidate or possibly no one at all. Blue Cross & Blue Shield of Mississippi officials call this “heartless” and claim that transplants was one of the areas in which it offered UMMC an increased reimbursement. This was when the hospital and the insurer tried to negotiate their contract. Cayla Mangrum of Blue Cross & Blue Shield Mississippi’s corporate communications manager said that most of these patients had been with UMMC for some time. She also stated that the tactics are destroying their relationship to their UMMC doctor. “UMMC’s reimbursement of transplants is fair, equitable, and based upon regional data.” However, Dr. Alan Jones, associate vice-chancellor for clinical affairs at UMMC, stated that Blue Cross does not tell the whole story. He said that although the insurer offered a slight increase in transplants, it was offset by cuts in other areas. The details of any existing contracts or negotiations between hospitals and insurers, even those state-funded, aren’t public. Chuck Stinson, Mississippi Organ Recovery Agency’s organ procurement agent that raises awareness on organ, eye, and tissue transplantation declined to comment. After receiving the call, the UMMC patient tried to find a solution. Blue Cross & Blue Shield of Mississippi representatives contacted him. They encouraged him to join the Methodist Transplant Institute list in Memphis. He said that the insurance company didn’t seem to be able to comprehend the complex, lengthy process of being evaluated and the difficulties of accessing care three hours away. He said that the Blue Cross adult case manager said “Oh, you’ll just go there and get assessed.” I replied, “Ma’am! It took four months to evaluate at UMMC.” “And who is going to pay me to travel back and forth from Memphis?” “I don’t know anyone in Memphis.” Transplant programs have different criteria so it’s not certain that he will be accepted. To be eligible, some require a specific MELD (Model of End-Stage Liver Disease). Some only allow one candidate to be listed on the transplant list at a facility while others allow multiple candidates. What if I don’t qualify after all the time and money I spent in Memphis? He said, “What if they don’t like someone who looks like me?” Because some insurance plans have limits on coverage, patients who undergo multiple hospital evaluations could be subject to high medical bills. In the hope that Blue Cross will pay some, he is still waiting for a cost estimate from UMMC. It is not clear if a payment agreement will be possible, as UMMC has stated that it will not accept payments from Blue Cross. According to an estimate of 2020 organ transplant costs, the average cost of a liver donation is $878,400. This includes costs for care in the month prior to surgery and six months afterward. When asked about the patient’s circumstances, Cayla Mangrum (manager of corporate communications at the insurer) said that if a Member wishes the UMMC Network benefits payment to be made to them, they can direct BCBSMS not to sign a Written Direction to Payment. A 2013 state law makes it illegal to balance bill a Member for amounts beyond their Network benefits. According to the law, a provider of health care cannot collect from patients any amount beyond their deductible, copay or coinsurance amount if they accept payment from a company that provides health insurance. If a hospital bills a patient $10,000, the hospital will pay $5,000 to the insurance company. The hospital cannot then collect the $5,000 remaining from the patient. The hospital cannot charge the patient any difference if the payment is made directly to them. When asked about the potentially life-threatening effects of the contract dispute on UMMC patients, both the hospital and the insurance company point fingers at each other. Mangrum stated that while we understand that some members may not wish to travel out of state to receive their transplant, it is UMMC who is refusing care for them. Jones stated that he hopes Blue Cross will “see the value” of the only state organ transplant program as well as UMMC in its entirety. “We are disappointed that patients with whom our relationship has been established may have to make difficult decisions about whether they want to be placed on a transplant waiting list at another facility. Jones said that they wish they were not faced with this process. It can sometimes take several in-person visits to a hospital’s surgeons and transplant program coordinators. “We believe it’s best for Mississippians who require a life-saving transplant to receive it in their home state.” The patient stated that while it has been stressful, it has allowed him to stay calm. He says that thinking about his children in the same situation is what really drives him. He’s heard that liver transplant recipients can live up to 30 years. “At my age, I don’t think I have the ability to live for 30 years, even with a healthy liver. A child with a poor MELD (Model of End-Stage Liver Disease Score) could have 30 years more of healthy living. They have their entire lives ahead of them. It is just too sad to imagine that anyone or any organization could stand in their way.