Blue Cross OKs initially denied Michigan Medicine kidney transplant
Blue Cross Blue Shield of Michigan said it has approved treatment for a member who needs a kidney transplant and sought care at Michigan Medicine, but initially was denied in-network coverage.
Blue Cross Blue Shield of Michigan said it has approved treatment for a member who needs a kidney transplant and sought care at Michigan Medicine, but initially was denied in-network coverage.
Blue Cross reversed its decision after the Detroit Free Press published a story Tuesday, May 5, about the denial, which was tied to dates of service and a contract dispute that has the state's largest health insurance provider and the Ann Arbor-based academic medical center of the University of Michigan at odds.
If negotiations don't result in a new contract by June 30, about 250,000 people with commercial Blue Cross plans will be forced out of in-network coverage with Michigan Medicine's physicians, clinics and hospitals, effective July 1.
Andy Hetzel, vice president of communications for Blue Cross, said a prior authorization request for the kidney transplant patient initially was submitted for a date that fell after the June 30 contract expiration deadline. Because of the timing, he said Blue Cross rejected it.
"Michigan Medicine resubmitted it with a date prior to June 30, and it was approved," Hetzel said, hours after the Detroit Free Press published a news story describing the denial of the transplant.
Dr. Scott Flanders, Michigan Medicine's chief clinical strategy officer, said the health system learned Tuesday evening that Blue Cross changed its decision on coverage for the transplant patient. Before the story was published, "the transplant referral had not been approved."
"We are relieved for the patient and their family," said Flanders, who also is an internal medicine physician and a professor at the University of Michigan.
Two appointments are now scheduled for that patient in the coming weeks at Michigan Medicine, he said.
More: Kidney transplant denied as Michigan Medicine, BCBSM dispute deepens
More: Blue Cross, Michigan Medicine contract fight: What patients should know
Transplant patients are among the 48,000 Blue Cross members with complex and serious medical conditions who may be eligible for a 90-day continuity of care extension that will allow them to continue seeing their doctors at Michigan Medicine until Sept. 29, according to the policy Blue Cross published this week.
However, without a new contract deal, even Blue Cross members who get that 90-day reprieve still will have to find new physicians after Sept. 29 or pay at least double the price of in-network care; some plan members will have to foot the entire bill for treatment at Michigan Medicine once it is bumped out of network.
Contract negotiations continue
More than six weeks remain in the current contract and negotiations are ongoing to broker an agreement on a new deal.
"These are hard conversations between two large, well-known, trusted institutions," Hetzel said, "and sometimes those types of conversations get difficult, especially when they're about money and especially now that employers in Michigan are finding it so hard to continue to provide affordable health insurance to employees."
The focus, he said, shouldn't be on individual high-acuity cases, such as the denial of a transplant procedure, but rather on the cost disparity between care at Michigan Medicine and other hospital systems in Michigan.
"They're already the highest paid system in the state," Hetzel said. "They're demanding significant increases in payment and we have concerns about the ability of our customers, our members to continue to afford health care and health insurance.
"We need to find a balance working in partnership with Michigan Medicine to achieve both access and affordability in this next contract with them. And we're hopeful that we can get there."
For its part, Michigan Medicine says its reimbursements from Blue Cross are 22% below those paid by other major commercial health insurers in the state. The Blues' proposed five-year contract, it says, would be an "unsustainable reduction.”
“We are advocating for an agreement that allows our nurses, physicians and care teams to maintain the high-quality, specialized care [upon which] patients depend, while we are also ensuring that care is accessible and affordable for patients across the state of Michigan,” said Michigan Medicine CEO Dr. David Miller in a previous story.
When setting reimbursements, Miller said Blue Cross shouldn't lump Michigan Medicine into the same classification as Corewell Health, Henry Ford Health and McLaren Health Care because Michigan Medicine provides unmatched specialty care where Michiganders with the most complex and rare conditions can get treatment. That work is expensive, he said, as is the research underway at the academic medical center that could lead to the discovery of new therapies.
Hetzel said Blue Cross considers about 11% of Michigan Medicine's total claims as complex and so specialized, patients couldn't go anywhere else in the state for that medical care.
"The other almost 90% ... is commonly provided by other health systems with just as much quality and just as good outcomes and at much lower cost," he said.
Blue Cross did not provide the Detroit Free Press with the raw number of claims or procedures it used to calculate the 11%.
Hetzel said it's the fourth year in a row that small employers in Michigan face double-digit health insurance premium increases driven by surging health care costs that include everything from hospitalizations to outpatient procedures, medical treatments and prescription drugs.
Blue Cross urges patients to find new doctors
On May 6, Blue Cross sent letters to members who have doctors through Michigan Medicine, urging them to start the process of finding new physicians with other health systems.
"We are recommending that our members take the appropriate steps and use this time to explore alternative options for care," Hetzel said. "We have a vast array of quality providers in southeast Michigan for them to choose from — systems with tremendous capabilities that work with us every day that accept our payments for our members' care."
"It's our hope to keep Michigan Medicine in our network. They are an incredible institution and we want them to be part of our network, but we need the payments that we negotiate to be affordable for people."
The cost of claims for Blue Cross went up by $5.6 billion in two years, Hetzel said.
"That is why health insurance premiums are under pressure right now. ... Hospitals account for 47 cents of every health insurance premium dollar that we collect. That's paid out to hospitals," Hetzel said. Another 25 cents of every health insurance premium dollar goes to other medical care providers, he said, and drugmakers get 20 cents per dollar.
"These upstream factors are very, very real and they're putting a lot of pressure on downstream health insurance costs and it's causing affordability problems everywhere in Michigan," Hetzel said.
He noted that many of the people who have serious medical conditions and use Michigan Medicine's health system also struggle to afford health insurance.
"At Blue Cross, we, on behalf of our members, want to achieve a balance between access to providers that our members want to choose," he said.
Michigan Medicine is creating "unnecessary worry and anxiety," Hetzel said, by sharing details with the news media about individual cases, such as the person who was denied a kidney transplant.
"We don't want that," he said. "Blue Cross does not want our members that access that system for critical illnesses and very serious health conditions to worry at all about our contract negotiations. But Michigan Medicine, by moving to terminate their in-network status on July 1, has put those people, unfortunately, right in the middle of the negotiations. And we don't believe that they should be there.
"If they were really that concerned about those people, they would not have moved to terminate their in-network status on July 1. It's central to their negotiation strategy to create this level of anxiety and worry."
Who will get the continuity of care extension?
Michigan Medicine sent messages to patients with Blue Cross insurance plans this week, telling them that nothing is changing right away about their access to in-network care at the health system.
"You do not need to cancel, change or transition any upcoming appointments or prescriptions" that are scheduled between now and June 30, the message said.
"If we do not reach an agreement ahead of the deadline, Michigan Medicine physicians, hospitals and services would be removed from the Blue Cross network, but Blue Cross is legally required under the No Surprises Act to provide extended in-network access for patients with certain chronic or serious conditions even if our contract ends. This extended access is known as continuity of care coverage."
Blue Cross also mailed letters and sent email messages May 6 to its 48,000 members who it says automatically prequalify for the 90-day continuity of care extension that will provide them access to Michigan Medicine physicians with in-network coverage until Sept. 29.
The company said members who are undergoing a course of treatment for a complex or time-sensitive condition may qualify, including those undergoing:
Active cancer treatment, such as chemotherapy, radiation or targeted therapy.Recent surgery requiring ongoing follow-up care.Organ transplant evaluation or recovery.Pregnancy with an established treating provider.Behavioral health treatment with active medication management.Complex or life-threatening conditions where interrupting care could be harmful.
However, routine monitoring for a stable condition may not qualify.
Flanders said the details of how continuity of care decisions are being made at Blue Cross have not been shared with Michigan Medicine.
"Blue Cross has yet to clarify for us how patients who do not automatically qualify will be evaluated or how the appeals process will work," he said. "It is deeply troubling that Blue Cross has ignored the input of the physicians, nurses, and care teams who know these patients best. Our priority is to minimize disruption and support patients in maintaining access to their care.”
Flanders said Michigan Medicine believes about 45,000 of its Blue Cross patients — roughly 15% — may qualify for the 90-day extension under the legal definition of continuity of care.
However, he said, "that figure does not capture the full scope of patients with serious or complex conditions who rely on Michigan Medicine for highly specialized care and may not fit neatly into standard definitions. Patients cannot be defined solely by a diagnosis code, and many come to us because of the unique expertise we provide, often after exhausting other options."
Michigan Medicine encouraged patients who did not get a notification from Blue Cross about being approved for the 90-day continuity of care extension to call the company using the phone number on the back of their insurance card.
"Decisions about eligibility and approval for continuity of care are ultimately up to Blue Cross, subject to applicable laws," Michigan Medicine's message to patients said. "Unfortunately, Michigan Medicine physician practices do not have access to or influence over these determinations by Blue Cross and cannot provide additional information about individual eligibility. If documentation is required by Blue Cross, your physician will be happy to provide it."
Contact Kristen Shamus: kshamus@freepres.com. Subscribe to the Detroit Free Press.
