Providence Health Plan has refused to pay claims for hospital patients in Hermiston if it later deems the hospitalizations unnecessary, leaving Good Shepherd Medical Center to eat the cost for treating those patients, hospital officials have told The Lund Report.
Jonathan Edwards, the director of patient financial services at Good Shepherd, said no other insurance company, not Moda Health, not Regence BlueCross BlueShield, second-guesses the hospital’s judgment about when a patient is sick enough to be admitted to the hospital.
“If we don’t do it right, we don’t get paid,” Edwards said. “Any time a contract supersedes a medical decision, that’s a concern for us.”
While that particular Providence business practice caused the most concern for the hospital, Good Shepherd spokesman Mark Ettesvold also laid out several other disagreements:
• Excessive semi-annual fees to be part of the Providence Preferred Network;
• Poor experiences with previous Providence Health Plan denials—the majority of which seem driven by technicality as opposed to health outcomes;
• An inability to contract with Providence for other services we provide, such as home medical equipment;
• A lack of direct contracting capability or claims resolutions with other payors that are part of the Providence Preferred Network; and,
• A one-sided approach of our current Provider Agreement (tilted heavily in favor of Providence).
Edwards said the sluggish negotiations and Providence’s untenable business practices shaped an internal hospital review that suggested it might be in Good Shepherd’s best interest to void its contract with Providence some time next year.
That possibility led Good Shepherd to mail a letter to Hermiston residents earlier this month during the enrollment period of the Public Employees Benefit Board, informing them that the Providence contract will likely end sometime next year, and they should consider other health coverage options -- which for state workers would be Moda Health.
PEBB members have until Friday to pick a health plan for 2015. If they’ve already selected a Providence Health Plan option but would like to switch, they have until the end of the year to request a change.
The public disagreement may have forced the two sides to work out their differences, as both Providence and Good Shepherd have sounded optimistic that a deal will be reached to avoid terminating the contract.
“Providence Health Plan had positive discussions this week with Good Shepherd,” said spokesman Gary Walker. “We have partnered with Good Shepherd Health Care System for more than 16 years, and look forward to continuing the relationship, providing access to affordable, high-quality health care in the Hermiston area.”
But despite the assurance of a Providence manager at last week’s PEBB meeting, Good Shepherd officials said the disagreements had been well known between the two parties for the past year, hence the letter.
“The point we wanted to make was that those subscribers could be at risk and that was our purpose,” Ettesvold said. “We anticipate a satisfactory [negotiation] of several items.”
In addition to the uncertainty that Good Shepherd faces in getting paid for hospital admissions, Ettesvold said the hospital had a high number of denials from Providence that were based on technicalities, not merit. “It’s an unacceptably high threshold to meet,” he said. “We can’t be constantly looking over our shoulders ... to make sure we get paid.”
Chris can be reached at [email protected]
