Debbie Birch’s kidneys failed last year. That made her one of more than 2,000 people in Idaho who regularly need dialysis, using a machine to filter their blood when their kidneys no longer do the job.
But the 63-year-old woman is now caught in a rift between a national dialysis company and her health insurer. No dialysis centers within driving distance of Birch’s home in Caldwell will take her insurance plan, the Bronze Choice plan sold on Idaho’s exchange.
It is unclear how many dialysis patients in Idaho this rift is affecting. But similar situations, which can limit choices and result in surprise bills, are increasingly common.
“What has happened — why we are so concerned and upset — is that we were with Blue Cross last year, when I was diagnosed with kidney failure,” Birch said. “We just went right next door (from the physician’s office) and started going to his Caldwell center for hemodialysis. ... We did that for three months, then we got a bill for $115,000.”
Even though her physician was “in network” — under contract to take Blue Cross insurance — the dialysis center next door was not. It was owned by a large dialysis company, Fresenius Medical Care, that was not doing business with Blue Cross.
“In network” health care providers agree to accept payments negotiated with the insurer. Patients pay only their premiums, deductibles and coinsurance or copayments. Idaho and most other states allow “out of network” health care providers to charge the patient for whatever portion of the bill is left after the insurer pays. For Birch, that “balance bill” was about $115,000.
$1,500 The charge: Your health care provider’s full price for a service.
$1,000 The out-of-network rate: What your insurance company pays for that service — if the provider is “out of network” with your insurance plan.
$500 Your responsibility: In Idaho, the provider is legally allowed to bill you for the remainder of the charge. This is called “balance billing.”
‘WE COULD LOSE OUR FARM’
Birch and her husband, Gary, were floored.
“We could lose our farm,” she said. “We called our insurance company, and they said, ‘Well, DaVita is in network, and it’s just down the street.’”
So, Birch switched to a center owned by another large dialysis company, DaVita.
That did the trick: Her bills were covered.
Until this year, around Feb. 1.
“We get a notice from DaVita (that) says we are no longer in network — Blue Cross of Idaho did not re-up our contract,” Birch said. “So my husband calls up Blue Cross and says, ‘What do we do? Who do we go to now?’ ”
That’s when they got the bad news. There was nowhere to go. Blue Cross plans sold on the exchange no longer cover any local dialysis centers.
An organization called the Chronic Disease Coalition contacted the Statesman about the issue in late February and connected a reporter with Birch.
Dialysis companies DaVita, Fresenius and US Renal started the coalition “to highlight patient discrimination issues in Oregon,” a media representative from the organization said, when asked about the coalition’s funding source. “It then grew into a larger organization to advocate for patients’ rights in additional aspects and for all chronic diseases as well as to advocate for national (research and development) efforts aimed at cures for chronic diseases.”
The coalition argues that insurers are discriminating against people who have chronic diseases. Those diseases are expensive to treat, and not having contracts in place with dialysis centers is a subtle way of pushing kidney patients out of Blue Cross plans, the coalition argues.
Blue Cross says that is not the case. It says it simply is trying to keep down health care costs.
Skip Thurman, a spokesman for DaVita, said the company has “never before seen a health plan terminate its network and leave dialysis patients with only one in-network option to receive treatment.” That center, he said, is in Idaho Falls.
DaVita has “appealed” the Blue Cross network decision “and all inquiries from DaVita to clarify Blue Cross’ decision and attempt to engage in a go-forward discussion have gone unanswered,” he said.
Of the other four insurance companies that do business on Idaho’s exchange, some of their plans have in-network dialysis in Idaho. PacificSource covers four centers and Mountain Health COOP covers six — none in the Treasure Valley. SelectHealth covers several centers, and so does BridgeSpan, including those Birch has used.
PATIENT FEELS CHEATED
Birch bought a health plan that was supposed to cover her dialysis. Now, her options are to deal with potentially astronomical medical bills or to cancel her current health plan and sign up for Medicare. Birch considered Medicare but says she determined it will actually cost her more money than her current insurance.
Blue Cross of Idaho spokesman Josh Jordan confirmed that the company no longer has contracts with either DaVita or Fresenius.
While the companies try to resolve their differences, both Blue Cross and DaVita said they are treating patients as though they are “in network.” At a minimum, that means patients will not have to meet a higher “out of network” deductible before insurance kicks in, or pay higher “out of network” copays; and they won’t have to pay DaVita for whatever Blue Cross doesn’t cover.
If this issue cannot be resolved, patients may face bills beyond their standard, in-network, maximum out-of-pocket (amount) due to Blue Cross of Idaho’s plan design and failure to provide an adequate network for their consumers.
Skip Thurman, spokesman for DaVita Healthcare Partners
But Birch worries that either company could rescind the “in network” waiver, raising her costs by thousands of dollars.
Having medical costs up in the air — relying on the benevolence of health care businesses — is difficult for Birch, who learned that her plan no longer included DaVita while she was recovering from a stroke.
“I was laying down on the bed and crying, and my husband said, ‘What can I do?’ and I said, ‘Let me go. Let me out of this nightmare,’ ” she said. “Then I know he gets to keep his farm and things like that, and that’s not what he wants. And yet, when you don’t feel good, and it’s all overwhelming. ... When you’re sick, and you’ve got no fight left.”
BLUE CROSS: MEDICARE RATES OR NO DICE
Gary Birch said he has negotiated with Fresenius, the company that sent the $115,000 bill. “Supposedly that should go away,” he said.
The couple also filed a complaint with the Idaho Department of Insurance, which declined to comment because the complaint is under investigation.
Jordan declined to say what is causing the lack of contracts between dialysis providers and Blue Cross. But it likely is related to money. Idaho law says insurance companies must contract with any providers that are willing to take the insurer’s terms and payment rates.
“For dialysis, we absolutely are willing to pay and attempt to negotiate with our providers — that we will pay for dialysis at the Medicare rate,” Jordan said. “We want to make sure we’re reimbursing providers at fair market value. In this instance, the federal government — Medicare — has applied what they consider to be a fair reimbursement rate for that service, and for the most part these people have access to Medicare.”
For the five most common dialysis procedures billed to Medicare in Idaho in 2013 — the most recent year in public records — providers charged an average of more than $400 per service. Medicare paid them an average of about $150.
Blue Cross would not want to have a provider out of network. Blue Cross would want a provider to be in network, if the provider is willing to accept fair market value for the services they are providing.
Josh Jordan, spokesman for Blue Cross of Idaho
Jordan said Blue Cross wants to work with companies that operate dialysis centers around the state, but those companies want to overcharge, he said.
“We desperately want to make sure that people have access to the care that they need,” he said.