COLORADO SPRINGS — Over two weeks since tens of thousands of Coloradans with Anthem insurance found themselves suddenly out-of-network with CommonSpirit Health, a health care advocacy group is urging Anthem and the Colorado Division of Insurance to file a complaint against CommonSpirit.
The Colorado Consumer Health Initiative (CCHI) is a non-profit, non-partisan health care advocacy group, according to its website. In a new statement to KOAA, they accused CommonSpirit of “prioritizing getting paid more” while leaving patients and community members in difficult situations to access care.
“While there is nothing that can force CommonSpirit to reach a reasonable contract or stop this behavior, Anthem and the Division of Insurance should file a complaint against CommonSpirit in the public hearing process for Colorado Option plans, as it could increase transparency on this issue,” said Adam Fox, Deputy Director for the Colorado Consumer Health Initiative (CCHI).
Fox feared the increases being sought by CommonSpirit will drive up health care costs for consumers. Though exact numbers aren’t known, Anthem has said CommonSpirit is demanding reimbursement rates “more than twice the rate of inflation.”
“This is not how ‘nonprofit’ hospitals should act in our communities,” said Fox in an email to KOAA.
Anthem and CCHI have both said CommonSpirit already has some of the highest reimbursement rates in Colorado. CommonSpirit said the new rates are meant to ensure it can protect the medical services it provides.
"My family has been severely impacted by this in the Springs and we’ve lost primary care and specialist access for our health conditions. I know we are not alone," said one KOAA viewer in an email. KOAA honored their request to not be identified.
"I don’t care if either side gets what they want, I just want it resolved," the viewer wrote.
WHAT DOES A COMPLAINT ENTAIL?
A spokesperson with the Colorado Division of Insurance (DOI) bluntly described the Colorado Option hearing process as “complicated.”
“Insurance companies must file Colorado Option Plan premiums that are consistent with the premium rate reduction targets in the law that established the Colorado Option,” said Vince Plymell, assistant commissioner for communications and outreach for the Colorado Division of Insurance. “These reduction targets set the trigger for the Commissioner of Insurance to use his authority to initiate public hearings.”
Essentially, these targets and hearings are meant to incentivize insurance companies to negotiate lower reimbursement rates with hospitals, and then pass those savings on to consumers with lower premiums. CCHI wants Anthem or the DOI to trigger this option in order to make the negotiations a more transparent process.
If an insurance company is unable to have its Colorado Option plan premiums meet the premium rate reduction targets, a company like Anthem would file a complaint against a health care provider like CommonSpirit, making their case as to why the provider is preventing them from meeting Colorado’s requirements.
The DOI can also file a complaint if it determines CommonSpirit is doing something that won’t allow Anthem to meet the requirement.
Plymell said at this point, he hasn’t seen a complaint filed by Anthem or the DOI and is unaware if they plan to.
“I think what we see is CommonSpirit owns and operates a couple key hospitals that are really essential for an insurance company like Anthem to have in-network. Otherwise, they technically cannot meet the standards for a provider network,” said Adam Fox with CCHI.
“And so I think that's a concern. Because if CommonSpirit ultimately isn't under contract, it means the Anthem provider network likely won't be sufficient.”
Colorado’s state standards for health insurance networks are more developed than the federal level. Since CommonSpirit operates key hospitals in the state like Merch in Durango and St. Anthony’s Summit in Frisco, those are essential for providing emergency services to those areas of the state. As such, they’re fundamental to meeting network adequacy standards, Fox said.
WHAT ARE ANTHEM AND COMMONSPIRIT SAYING?
CommonSpirit took an optimistic stance on negotiations with a new statement sent to KOAA around 3 p.m. on Wednesday.
“We are pleased to share CommonSpirit Health and Anthem Blue Cross Blue Shield have had positive conversations in the last 25 hours,” said a CommonSpirit spokesperson. “While there is a glimmer of hope, we still have more ground to cover to ensure we can retain the compassionate doctors and nurses who care for our communities.”
CommonSpirit called their rate increase proposal “fair and reasonable” and said they would continue advocating for their patients.
Anthem took a more abrasive approach with an update to their dispute.
“As of today, CommonSpirit continues to insist on unacceptable price increases for Colorado consumers and businesses,” said an Anthem spokesperson. “Disrupting patient care to drive up costs is a standard practice for CommonSpirit, one they’ve recently used in several other states as well.”
The statement references similar disputes in other states such as one seen in Arizona earlier this year between Anthem and Dignity Health, which is part of the CommonSpirit network. Once that contract expired, it took nearly two months until the two sides agreed to terms.
Anthem said they remain at the negotiating table. In response to CommonSpirit’s more optimistic statement, Anthem said they can’t comment on the progress of negotiations, but that ongoing conversations are “always a good thing.”
WHAT CAN YOU DO IF YOU’RE IMPACTED?
The Colorado Division of Insurance urged anyone experiencing issues with Anthem not responding to contact their Consumer Services Team at 303-894-7490 or DORA_Insurance@state.co.us.
More information can also be found on the DOI FAQ page.
Anthem is encouraging members to call the numbers on their cards with concerns. The company has a web page dedicated to the dispute.
Similarly, CommonSpirit has their own web page detailing their perspective. Those in active treatment with a CommonSpirit hospital can seek out Continuity of Care benefits.
The Colorado Consumer Health Initiative said it’s working to add a fact sheet of support options to its website, but meantime, consumers can reach out to their Consumer Assistance Program at 303-839-1261, help@cohealthinitiative.org, or send an inquiry to cohealthinitiative.org/need-help.
Emergency services are always covered even at out-of-network facilities without prior authorization.
CCHI also said consumers may qualify for a network adequacy exception, which they detail below.
Network Adequacy Exception. If an in-network provider is unavailable within a reasonable distance2, you can request a network adequacy exception. A network adequacy exception will allow you to receive services from CommonSpirit at in-network benefit rates, you will only be responsible for your in-network cost-sharing amounts (copays and coinsurance). Anthem will also be able to help you find other in-network providers for the care you need.
To request a network adequacy exception, you or your health care provider may contact Anthem by calling the number on the back of your insurance ID card, calling member services at 855-837-8536, or by logging into your online account and sending an electronic request.
For previous coverage of this story, you can visit this link.
Email Senior Reporter Brett Forrest at brett.forrest@koaa.com. Follow @brettforrestTVon X and Brett Forrest News on Facebook.
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