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Young patients caught in conflict between MCG and Blue Cross Blue Shield

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Gretchen Daly looked down the counter at Dairy Queen and spotted her 10-year-old son, Carter, getting ready to pop behind the counter and make Blizzards.

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Dairy Queen franchise owner Asim Momin, helps Carter Daly, 10, make a frozen treat during a fundraiser for the Children's Miracle Network, benefitting Medical College of Georgia Children's Medical Center. Carter receives care for type 1 diabetes at MCG, but the flap with Blue Cross Blue Shield of Georgia has his family concerned.  EMILY ROSE BENNETT/STAFF
EMILY ROSE BENNETT/STAFF
Dairy Queen franchise owner Asim Momin, helps Carter Daly, 10, make a frozen treat during a fundraiser for the Children's Miracle Network, benefitting Medical College of Georgia Children's Medical Center. Carter receives care for type 1 diabetes at MCG, but the flap with Blue Cross Blue Shield of Georgia has his family concerned.

“You know it’s 100 grams for Blizzards,” she tells him.

“It’s 100?” Carter said incredulously as he reached for his insulin pump and sent out a big dose of insulin after snarfing down one of the frozen treats.

Even as they help in a fundraiser to benefit the Children’s Miracle Network and Medical College of Georgia Children’s Medical Center, the Daly family is facing the potential loss of the hospital and its doctors because of a contract dispute between the hospital and their insurer, Blue Cross Blue Shield of Georgia.

The hospital and its physician practice group have given notice to Blue Cross patients that it is terminating its contract with the insurer as of Aug. 15 because 10 months of negotiating a rate increase have gone nowhere.

The practice group, whose rate was last reset in 2003, said it would like a 13 percent increase, or about 1.4 percent per year over those nine years. It amounts to about $400 more per physician per year, said Dr. William Kanto, the chief medical officer for both the health system and the physician group.

“It’s not going to enhance very much the income of the physicians, but it will help us offset the cost of care,” he said. “And everyone I think realizes that the cost of care has gone up over nine years. And it is not fair to expect one group to accept that responsibility. And certainly the premiums have gone up significantly more” than 13 percent over nine years.”

MCG officials said Blue Cross has countered with a 3 percent offer it has refused to budge from; Blue Cross claims it has made several offers to try and reach an agreement.

Both sides say they are continuing to talk but accuse the other of not
responding to recent offers.

For the Daly family, it means facing an uncertain future. They moved back to the Augusta area from California in 2006 to be closer to family in McCormick, S.C., Gretchen Daly said.

“MCG was really one of the main reasons we moved to this area,” she said. “We were coming back to be closer to family, and I did a lot of research on where we could bring Carter where he would have the best care.”

Carter was diagnosed with type 1 diabetes at 20 months, and he sees MCG pediatric endocrinologist Chris Houk at least four times a year.

“My hope is that they can work things out and reach some sort of amicable agreement,” Gretchen Daly said. “It would be very hard to find another facility that will take care of Carter the way he is taken care of here.”

It would also mean losing extra services such as Camp Sweet Life for children with diabetes, which is run through the MCG program.

But Kanto, who was the chairman of the Department of Pediatrics at MCG for many years, said the physicians will work something
out, even without Blue Cross.

“We as a practice group are not going to abandon the patients,” he said. “We wish Blue Cross Blue Shield would address the issue of continuity of care as is required in the contracts. But we have been thwarted and frustrated by their inability or unwillingness to help us address this issue.”

In a statement issued Thursday, Blue Cross said patients in active treatment at MCG can seek to have that continue for a limited time at in-network rates.

Care that cannot be provided elsewhere might be covered longer but is determined on a case by case basis.

The MCG hospitals and health system are very close to reaching an agreement with Blue Cross, but because of the problem with the physician, rates will have to break with the insurer because otherwise there would be no one to see the patients, or it would create billing and benefit nightmares, Kanto said.

As far as funding from Blue Cross goes, perhaps it would have been better to be a shareholder than a physician in this case, he said.

“We would probably have done better if we took our money and invested it in their stock nine years ago,” Kanto said.

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fedex227
11187
Points
fedex227 07/26/12 - 10:55 pm
4
2
Of course the Daly's can always...
Unpublished

cancel their insurance with Blue Cross, sell their home, cash in their 401K's, liquidate all their assets, dissolve themselves of any substantial income, apply for Medicaid, and provide the necessary medical care for their child. Welcome to the American health care system.

OhWell
326
Points
OhWell 07/27/12 - 05:08 am
1
1
WHY did MCG not negotiate

WHY did MCG not negotiate their rate each year as most hospitals and phsycian groups do? This is a BIG error on MCG's part. Have the other commercial payers contracts been rewiewed such as UHC, Humana, Aetna and Cigna?

Riverman1
84919
Points
Riverman1 07/27/12 - 05:37 am
5
0
We need to ask Blue Cross

We need to ask Blue Cross what the other hospitals receive. There's nothing wrong with competition.

GaStang22
910
Points
GaStang22 07/27/12 - 05:38 am
0
0
PPG, MCG, and insurance companies rob you
Unpublished

PPG and MCG shouldn't need to increase anything when they have some doctors charging people for services they don't give and refusing to take it off people bills. They are dirty and give inadequate care. We've done had 4 doctors do that. They leave you in pain, yet bill for the procedure they should have done to get you out of your pain. Then magically.....your medical records are no where to be found!!! The insurance companies are no better. A 25% premium increase after the first year when you've paid 300 times in premiums what they paid for 1 measly little bill. Whole thing is sickening.

skeptical
84
Points
skeptical 07/27/12 - 06:27 am
2
1
WHY did MCG not negotiate???

Sorry, OhWell, but hospitals and groups DO NOT renegotiate fee schedules with insurers yearly. They all pursue relatively long-term contracts so the we don't have to go thru this nonsense with the insurance companies EVERY year . . .

OhWell
326
Points
OhWell 07/27/12 - 06:33 am
3
1
RM that was my question

RM that was my question yesterday if they are all in line there is not much MCG can do. If there is a big varience then they have negotiating power!

Skeptical, that is not the way hospitals I work with handle there fee schedule. If you get 1 to 1.5% every year or so you stay in line and the negotiations are much smoother. Yes you do lock in your contract for a period of time but 9 years is unrealistic.

Fiat_Lux
15677
Points
Fiat_Lux 07/27/12 - 09:21 am
3
0
If this stalemate sticks...

and you rely on BCBS for coverage, you'd better pray your child doesn't show up with cancer or some other disorder that can only be treated at a big institution with specialty clinics. You'll have a long drive every week or month to get to CHOA or MUMC in Savannah, and the added expense of overnight stays.

Oh, yeah. This is just wonderful. And BCBS is always soooo helpful and easy to deal if you are one of their policy-holders.

soccerfan
18
Points
soccerfan 07/27/12 - 10:48 am
3
0
Its admirable that MCG is

Its admirable that MCG is holding firm. BC/BS has increased premiums several times in the last ten years to its customers, health care costs for supplies at hospitals have risen, and they still want to pay the hospital the same amount they did 10 years ago so whose pocket did that premium increase go into? BC/BS is squeezing both ends.

dichotomy
33528
Points
dichotomy 07/27/12 - 10:57 am
2
0
Went through this with Blue

Went through this with Blue Cross and St. Joe years ago. What a pain. Fortunately it did not last very long before they reached an agreement.

I wonder how much negotiating room the hospitals will have under Obamacare?

Willow Bailey
20603
Points
Willow Bailey 07/27/12 - 02:39 pm
1
0
Dr. Azziz make this a top priority & handle it!

I've been stewing over this since getting my letter from MCG. It certainly grieves my heart for the pediatric patients, but everyone who has been seeing physicians at MCG with BCBS of Ga. is in a dilemma if your needs require specialists. How do you stop in the middle of cancer treatments and find a new endocrinologist or oncologist? Some specialties have very long waiting lists. Get this mess fixed! It's so not coool!

Fiat_Lux
15677
Points
Fiat_Lux 07/27/12 - 07:02 pm
1
0
After talking to some people

at GHSU, I've about decided that BCBS is essentially an exploitative, bottom feeding company. They haven't raised what they pay MCG for services in 9 years. NINE YEARS without an increase.

I still can't get my head around that, especially the way medical costs have continued to soar out of sight.

The thing that make BCBS look so despicable in all this is that over the last nine years of not paying out any more, the costs of premiums have started looking like mortgage payments instead of just another car payment.

So where is all THAT money going if not to the care providers?

Martinez
154
Points
Martinez 07/27/12 - 11:29 pm
0
0
Rediculous

I have seen my premiums more then double in ten years so why is it that nothing additional is paid out to the actual physicians that provide the service? Isn't BC/BS one of the companies that fought the hardest over the MLR rebates and requested a waiver of 80/20 rules? Pure Greed!

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