Failed negotiations makes major insurance provider ‘out-of-network’ in Colorado

COLORADO SPRINGS, Colo. (KRDO) - Tens of thousands of Coloradans covered by Anthem Blue Cross Blue Shield will likely have to pay expensive out-of-pocket prices for services at CommonSpirit facilities.

The two large healthcare corporations couldn’t reach a contractual agreement Wednesday morning, meaning Anthem members are now considered out-of-network at all CommonSpirit facilities.

CommonSpirit said it offered Anthem a temporary contract extension to keep its members in-network, but Anthem denied it because it would “cause more confusion for our members.”

The two companies said they can’t agree to terms over reimbursement rates. CommonSpirit is asking for higher rates to keep up with inflation and cost of care, while Anthem is looking for lower rates for its members. CommonSpirit claimed it lowered its asking price while Anthem hasn’t budged.

“We can't have them continue to stonewall us around any of the work that we're doing for our patients because it's going to hurt patients in our communities,” said Ozzie Grenardo, the Chief Medical Officer for the Mountain Region of CommonSpirit. “We've moved such that we're really trying to get to that fair, reasonable point because we don't want to have to decrease the services that we provide nor have any disruption in those patient care services that we're giving to our patients.”

Anthem declined an interview with KRDO13 Investigates but in a statement said this is a “negotiation tactic to demand unreasonable price hikes.”

“After months of unreasonable reimbursement requests, CommonSpirit is now asking for a one-week extension only after they have disrupted care for our members,” Anthem said in a statement. “Short-term solutions will only cause more confusion for our members.  CommonSpirit has established a pattern of disrupting care for its patients as a negotiation tactic to demand unreasonable price hikes. CommonSpirit recently used this tactic in Arizona, California, and Nevada – leaving other health plans’ networks for as long as 45 days. Anthem remains fully committed to reaching a collaborative, multi-year agreement with CommonSpirit will give Anthem members the access to affordable healthcare that they deserve.”

This loss of coverage affects about 40,000 Coloradans. Many will likely have to travel further to find an in-network provider for services or pay high out-of-pocket prices if they decide to stay at CommonSpirit facilities, which include 11 hospitals and dozens of clinics.

The Colorado Consumer Health Initiative, a non-profit, non-partisan healthcare advocacy organization, said CommonSpirit has more leverage in negotiations. Many of its hospitals are in rural Colorado, and Anthem is required to have enough providers to meet its members’ needs.

“Anthem has to ensure that there's care that's accessible for all of their members within their network and right now it wouldn't be,” said Priya Telang, the communications manager at the Colorado Consumer Health Initiative. “They do have a responsibility to their patients to come to an agreement but so does CommonSpirit in a way that's not damaging to every single consumer's finances.”

There’s a chance some services will still be covered. Telang said emergency services are covered regardless of whether the facility is out of network, and specialized care, like chemotherapy, could be covered if Anthem approves. It’s the routine services that likely won’t be in-network.

Grenardo said he hopes Anthem will honor any claims made by patients between now and when they reach an agreement. However, that could be a major risk for Anthem members. KRDO13 Investigates reached out to Anthem to ask about this but we haven’t received a response back.

“There have been measures across the state of Colorado to reduce costs and hospitals tend to be the primary drivers of increased health care costs,” Telang said. “It's going to be an interesting argument that's going to play out over the next few weeks or months.”