BCBS and Mission Health still haven’t reached a deal


Brittney Burns – Staff Writer

The clock continues to tick for Blue Cross Blue Shield of North Carolina and Mission Health System, whose contract is scheduled to be terminated on Oct. 5 due to failed negotiations efforts.

Mission Health System, with facilities and provider practices in Western North Carolina communities including Angel Medical Center in Franklin, notified Blue Cross and Blue Shield of North Carolina (Blue Cross NC) that it plans to leave the network effective Oct. 5, 2017. The health system has chosen to become the only system in North Carolina outside of Blue Cross NC’s network. All Mission Health hospitals, outpatient facilities and most physicians will be out of network beginning Oct. 5. Some Mission Health physicians within the health system will remain in network until March 2, 2018.

Mission Health’s decision means that most Blue Cross NC customers who receive care at a Mission Health facility, or from a Mission Health provider, will need to either seek care elsewhere, or possibly pay more out-of-pocket. Customers can always access emergency care as in-network care. Additionally, services qualifying for Blue Cross’s continuity of care program will be considered in-network.

With just over a month until the contracts are set to end, leaders in Macon County are developing plans on what to do for employees if the contract is effectively terminated.

County Manager Derek Roland said that Macon County officials are also closely watching the situation and have been in contact with the county’s insurance providers to ensure that regardless of an outcome, Macon County employees continue to receive the same level of insurance and have the same access to providers as they currently do.

“Our town manager has been communicating with our insurance broker concerning options for town employees currently on Blue Cross,” said Highlands Manager Patrick Taylor.  “We both met with representatives from Mission this past week. I came away from the meeting with the sober realization that the current contract between Blue Cross and Mission will very likely expire on Oct. 5. While Blue Cross will continue to fully cover emergency services, Blue Cross policy holders will be treated

as being out of network for primary healthcare claims at Mission facilities, including our hospital.

“I expect negotiations to resume after Oct. 5, but in the meantime we will continue to explore better options for our employees. From this controversy the town may be able to provide the same level of care for employees at lower costs.”

Mission Health Chief Executive Officer Dr. Ron Paulus hosted a question and answer session on Facebook earlier this month to answer questions from patients regarding the health care system’s ongoing contract battle with Blue Cross Blue Shield of North Carolina.

Dr. Paulus explained that the decision to cancel the contract wasn’t a hasty one, but rather something that was debated between the two parties for six months before a decision was announced. Paulus said Mission would have had to accept a new contract with a reduction in payments for the next three years or just let the current contract renew automatically Oct. 5 and accept a zero increase in payments for the next several years. Blue Cross said they wouldn’t accept any increase request from Mission to keep insurance costs low for patients.

“Imagine never getting a pay increase at work while the costs of living continue to rise,” Paulus said. He noted that drug costs have increased 12 to 16 percent, medical supplies are up 8 percent and Mission gave employees a 3 to 4 percent raise last year. With the increase in operating costs such as raises for employees, patients would need to pay more to balance the hospital system’s budget.

Mission has developed a program to serve patients who choose to keep Blue Cross, even if a contract isn’t met between the two companies. Mission Health has outlined a plan to help consumers affected by the inevitable end of its current contract with BCBSNC on Oct. 5, 2017.  Mission’s transition plan will cover everyone with BCBSNC insurance coverage, including consumers with BCBSNC commercial insurance coverage and BCBSNC Medicare Advantage plans.


“Now that we know BCBSNC’s final decision is to refuse to even speak with Mission, we are completing plans and associated logistics for this important transition,” said Paul McDowell, Deputy Chief Financial Officer for Mission Health. “Mission Health is committed to helping consumers through this difficult change to the degree humanly possible, and we will have the final details worked out in the next few weeks.  This is a sad situation.  Not only do we wish this issue didn’t exist at all, we also wish it was simple; but it’s very complicated.  Particularly so because BCBSNC will not provide Mission with access to the customer and member agreements that specify covered benefits.  Mission will do everything it can, within the boundaries of the law and an employer’s benefit plan, to ease this unnecessary transition burden on consumers.”

For Consumers

There are significant exceptions to the problems created by the expiration of Mission Health’s contract with BCBSNC.  First, state law prohibits BCBSNC from financially penalizing fully-insured patients when a participating provider is not available without unreasonable delay.  This prohibition is critically important for patients and is a legally significant issue.  Because Mission is the only provider of certain services within the region – including but not limited to heart surgical services, pediatric specialty services, high risk maternity services and others – Mission will be assisting impacted patients to make full use of this important law’s consumer protections.  Unfortunately, this state law does not apply to consumers with self-funded employer coverage.


Second, to reduce harm to consumers, Mission will provide a generous, prompt payment discount to the balance of a patient’s bill after taking into account the patient’s personal financial responsibility.  That discount will be applied when patients send their explanation of benefits (EOB) and any check received from BCBSNC to Mission Health within 10 days.  This process is designed to manage any circumstance where BCBSNC may send benefit payments directly to the patient rather than to Mission Health as the service provider.  This practice, already illegal in the majority of states in America, is something that BCBSNC has routinely threatened to do.

“While we are helping employers through this transition, BCBSNC can help their customers by honoring each patient’s assignment of benefits election,” said McDowell. “There’s no reason whatsoever for BCBSNC to send checks to patients once Mission Health is out of network – other than trying to harm Mission and unduly worry consumers.   … What every employer and patient wants is for their insurance company to do what a patient has asked by making all payments exactly as they have elected.” Mission Health also encourages patients to demand in writing that BCBSNC honor their assignment of benefits election so that they are not unduly burdened when they are sick or injured and Mission Health can respond to any BCBSNC errors.


For All Employers

The most important factor for employers to consider is whether they will stay with BCBSNC after Oct. 5 and lose in-network access to Mission Health or whether they will evaluate other highly competitive health benefit options that include Mission Health.  “The really great news for every employer in the region is that Mission Health’s new contracts with Aetna and Cigna provide previously unavailable, affordable choices in the region that keep Mission Health in network,” said McDowell.  Further, Mission Health will work collaboratively with any employer considering a switch from BCBSNC to another insurer to make the transition as easy and seamless as possible for them and for their employees.


For Self-Insured Employers

Aetna, Cigna and Healthy State each offer previously unavailable and highly competitive alternatives to BCBSNC.  This is important news in that the state law prohibiting BCBSNC from financially penalizing fully-insured patients when a participating provider is not available without unreasonable delay does not apply to self-insured plans. Any self-insured employer that intends to remain with BCBSNC will need to specifically direct BCBSNC to continue to pay benefits on its behalf as in-network if the employer desires to protect its employees during this transition time.  A self-funded employer’s plan is its own – and not BCBSNC’s plan – so the employer controls what BCBSNC does on its behalf.

Additional details are expected to be announced by next week.

While continuing discussions with Blue Cross, which provides coverage for around 70 percent of the state’s private health insurance market, insuring about 3.5 million people in the state and in 16 WNC counties, about 260,000 people, Mission has approved contracts with smaller health insurance providers.

WellCare of North Carolina, a subsidiary of WellCare Health Plans, Inc., a leading provider of Medicaid and Medicare services, announced this week that Mission Health will join the health plan’s provider network.

As of June 30, 2017, WellCare serves approximately 33,000 Medicare Prescription Drug Plan members in North Carolina.


WellCare’s members will have full access to Asheville, N.C.-based Mission Health System’s full spectrum of healthcare services. The providers include six hospitals, numerous outpatient and surgery centers, post-acute care provider CarePartners, long-term acute care provider Asheville Specialty Hospital, and the region’s only dedicated Level II trauma center.


“Our members’ health is our first priority, and we must ensure that they get the right care at the right time in the most appropriate setting,” said Gregg MacDonald, senior vice president, division president at WellCare. “Mission Health System is a strong addition to our network of providers. We look forward to working with them to help our members live better, healthier lives.”


Headquartered in Tampa, Fla., WellCare Health Plans, Inc., focuses exclusively on providing government-sponsored managed care services, primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, to families, children, seniors and individuals with complex medical needs. WellCare serves approximately 4.4 million members nationwide as of June 30, 2017.