HVHC | Empire Blue Cross Blue Shield News

New York, June 30, 2009 – Empire BlueCross BlueShield and Pinnacle Healthcare hospitals -- Hudson Valley Hospital Center, Sound Shore Medical Center and Mount Vernon Hospital -- announced today that they have reached an agreement on a new contract, effective July 1, 2009. Under the multi-year agreement, Empire members will continue to have access to Pinnacle Healthcare hospitals as in-network providers.

Speaking for Pinnacle Healthcare, John Federspiel, President of Hudson Valley Hospital Center, said: “We’re pleased that we have reached a contract agreement following a difficult and challenging negotiation. Pinnacle Healthcare hospitals remain committed to providing our local communities with the finest quality healthcare in the region.”

“We are pleased to continue our long standing relationship with Pinnacle and help them support their ongoing mission of providing important health services to our members and to the Westchester community while managing health care costs in this difficult economy,” said Mark Wagar, president and CEO, Empire BlueCross BlueShield.

No action is required by Empire members to continue services at any Pinnacle Healthcare facility. Members with questions about their plan or coverage can contact their specific member service representative at the number on their ID card. General information can be found at .

Deadline looms in negotiation between hospitals and insurer

CORTLANDT MANOR – As many as 50,000 Empire Blue Cross Blue Shield subscribers in Westchester County may need to find new doctors and hospitals next month if an agreement is not reached with Hudson Valley Hospital Center, Mount Vernon Hospital and Sound Shore Medical Center. All three hospitals operate under the umbrella of Pinnacle Healthcare, Inc.

The bad blood in the negotiation process between the for profit Empire Blue Cross Blue Shield and non-for-profit hospitals involves reimbursement rates and approval for major services by the insurer, according to John Federspiel, president of Hudson Valley Hospital Center (HVHC).

Empire Blue Cross Blue Shield is owned by the Indianapolis-based WellPoint, Inc., the nation’s largest health benefits company.

Federspiel said that WellPoint, Inc. is putting profits in front of patient care. Hospital officials said that Empire is reimbursing them at a similar rate as Medicaid and Medicare. “We need a 25 to 35 percent increase from Empire in order to serve their subscribers,” said Federspiel.

Family members of elderly hospital patients spoke out at a news conference. Aline Morris’ said her elderly mother has been denied rehabilitation services by Empire following emergency treatment for a stroke at Hudson Valley Hospital Center. “Time is slipping. She has had a stroke and there is a window of opportunity, as I understand it from doctors that she has a chance to recover. That time is being spent upstairs. Empire needs to come through,” said Morris.

Empire Blue Cross Blue Shield issued a statement on June 12 outlining their service approval policies and process: “All medical treatments are determined by a patient’s physician—and is never prescribed or denied by Empire Blue Cross Blue Shield.”

In the same statement, Empire raised questions about the community hospitals’ efficiency and reimbursement increases in the past. At the news conference, the community hospitals flatly denied the claim that they have been operating inefficiently.

WellPoint said their operating revenue in the first quarter of 2009 as being $15.3 billion. “The benefit expense ratio was 81.6 percent in the first quarter of 2009, a decrease of 350 basis points from 85.1 percent in the prior year quarter.

The decline resulted principally from disciplined pricing and operational improvements in the Senior and Local Group businesses,” according to a company’s news release.

Bonnie Raab of Putnam Valley believes her mother’s treatment was delayed due to the insurance company’s red tape and for profit status. “At 86, Blue Cross Blue Shield shouldn’t make her an invalid, which is what they kind of decided on June 9. They decided she didn’t need rehabilitation. What was the point? She was very independent and we want her back,” said Raab.

MidHudsonNews.com has learned that Empire has since approved rehabilitation services for Mrs. Raab.

Federspiel said that Empire was a not-for-profit entity during their last negotiation three years ago. Negotiations then were arduous, but not acrimonious, said a hospital official. “WellPoint is trying to map on—or layer on—their national approaches they have used in California and other regions of the country here in New York,” said Federspiel.

If an agreement is not reached by the deadline, even doctors practicing at Hudson Valley Hospital Center will have to affiliate with other hospitals.

Empire insures employees of the Hudson Valley Hospital Center and the City of Peekskill, according to speakers at the news conference.

Neale Sanchez, a chronic diabetic, said he does not want to have to drive 30 minutes to another emergency room if the Empire Blue Cross Blue Shield contract expires on June 30.

Hospitals protest stalled contract talks with Empire

CORTLANDT - Doctors, patients and administrators rallied outside Hudson Valley Hospital Center in protest of proposed new reimbursement rates with Empire BlueCross BlueShield.

Hudson Valley Hospital, Mount Vernon Hospital and Sound Shore Medical Center of Westchester in New Rochelle would leave Empire's network if contract talks aren't settled by the end of Tuesday.

"We've been trying to negotiate for the better part of nine months to try to get a new three-year agreement," Hudson Valley President John Federspiel said. "We're very frustrated with the negotiating process."

Empire is the state's largest health-care insurer at 5 million members. It was acquired by WellPoint Inc. of Indianapolis in 2005.

The three Pinnacle Network hospitals had a combined 27,000 visits each of the past two years by Empire consumers.

Empire sent letters to members dated May 31 that noted the continuing negotiations and provided a list of other regional hospitals in Empire's network that members could use.

Bonnie Raab of Putnam Valley said her 85-year-old mother underwent hip surgery at Hudson Valley and has waited two weeks for Empire to authorize her transfer to a rehabilitation facility.

"We're paying BlueCross BlueShield above her Medicare. If she had straight Medicare she would have been in rehab two weeks ago," Raab said. "They're taking the money, and they're clearly not giving it to the hospital."

"I don't think most people realize what's going on unless they're chronically ill," said Neale Sanchez, a 46-year-old diabetic from Continental Village. "I use my health care all the time."

Empire spokesman Craig Andrews said the company remains optimistic a deal will be reached by the deadline and defended the proposed rates.

"There's a bunch of things that we take into consideration," Andrews said. "Obviously we're representing our members and customers, but also we understand that hospitals have costs too, and we take that into consideration also."

3 Westchester hospitals, Empire Blue at odds over reimbursements

Three Westchester hospitals and hundreds of doctors would leave the Empire Blue Cross Blue Shield network if negotiations for new reimbursement rates aren't successfully concluded by the end of the month, the hospitals said yesterday.

Representatives of Pinnacle Healthcare's hospital network - Hudson Valley Hospital Center in Cortlandt, Sound Shore Medical Center of Westchester in New Rochelle and Mount Vernon Hospital - said they were making little progress in the talks.

"We have a long history of working with them. Unfortunately, this negotiation has been very difficult. They've taken basically a take-it-or-leave-it approach," Helen Turchioe, Pinnacle's executive director, said at a press conference yesterday.

"We've been in negotiations all week, which isn't a take-it-or-leave-it activity," Empire spokesman Craig Andrews responded afterward. "We're negotiating, particularly in this economy, with an eye toward maintaining affordability of health care."

With 5 million members in New York state, Empire is the largest health-care insurer in the state. It was acquired by WellPoint Inc. of Indianapolis in 2005.

Pinnacle hospitals had 27,000 visits last year by Empire consumers, about the same as in 2007, Turchioe said.

Contract talks between Pinnacle and Empire went down to the wire at the end of 2006, when the last contract was set to expire. The two sides reached a deal and consumers were not shut out of services.

Empire sent letters to members dated May 31, in which it said it was "working diligently, and in good faith" to reach a deal with Pinnacle. The letter provided a list of other regional hospitals in Empire's network that members could use.

Hospital officials said Empire network doctors who held admitting privileges exclusively at the Pinnacle hospitals would be dropped from the network if a new contract can't be reached by the deadline. They have an appeals process, however, that would keep them in Empire for about eight weeks at a minimum.

It was the opening salvo in a public campaign that will include ads to lay out the hospital's position.

The three hospitals lost a combined $16 million last year, Turchioe said. She and others portrayed Empire as a profitable insurer whose practices were harming patient health care.

County Association President William M. Mooney Jr., a critic of health insurers, said that business health-insurance premiums have risen 119 percent in the past 10 years, while reimbursements to hospitals have gone up just 1 percent to 2 percent. WellPoint's earnings last year were $2.3 billion, he said.

Premium increases are related to the overall cost of health care, which is rising, Andrews said. Empire's profit margin is in the low single digits, he added.

Linda Piccirilli, vice president of quality management at Hudson Valley Hospital, said Empire has denied about 30 percent of the hospital's initial admission requests, well above the denial range of 2 percent to 6 percent from other insurers, she said.

Empire overturned its denials 85 percent to 90 percent of the time, she added.

Andrews said the 30 percent figure "seems a little high." He said the initial denials in most cases are the result of the hospital failing to provide supporting data for the admission, an assertion that Piccirilli challenged.

The review process for reimbursement denials includes an outside panel, and can be reviewed by the state Insurance Department, Andrews said.

"It's never about getting in the way of someone's care, never," he said.

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Empire Blue Cross Blue Shield News

Breaking news: Hudson Valley Hospital Center and Empire BlueCross BlueShield Announce Agreement

Deadline looms in negotiation between hospitals and insurer

Hospitals protest stalled contract talks with Empire

3 Westchester hospitals, Empire Blue at odds over reimbursements