Rural system, insurer call off battle
The long and bitter fight between a struggling rural health care system and Texas’ largest insurer appears over as the flagship hospital in Tyler will now be included in the carrier’s in-network group plans, both parties confirmed Thursday.
East Texas Medical Center captured national attention when it took the extraordinary step of suing Blue Cross and Blue Shield of Texas and its Chicagobased parent company last summer in state court alleging that the insurer had plunged it into financial ruin and put patients with specialized needs at risk by shutting the main hospital in Tyler out of the most common and popular group health insurance network.
Blue Cross and Blue Shield, which is estimated to command about 73 percent of the market share in the region, had countered that the hospital was using the courts as a negotiating tool and that it was exaggerating its financial woes, which, even if true, were not the fault of the insurer, according to testimony in a contentious court proceeding last fall.
The insurer also said in court that its provider network in the region was adequate in the eyes of the Texas Department of Insurance and the lawsuit could lead to a dangerous precedent among other unhappy providers.
The case, possibly the first of its kind, offered a rare glimpse into the high stakes attached to the arcane world of insurer network designations. With emotions high, it seemed destined for a showdown at trial early next year.
But the impasse was
broken last week during mediation, according to a statement from the hospital system on Thursday.
While the terms are not finalized or made public, the 502-bed facility in Tyler is in-network for Blue Cross and Blue Shield group preferred provider plans, or PPOs, under the agreement. ETMC was already included in the Blue Cross and Blue Shield’s group health maintenance plans, or HMOs, and on its Affordable Care Act’s federal exchange offerings.
On Monday, state District Judge Jack Skeen gave both sides 45 days to prepare settlement documents.
“We are very pleased that our patients can choose ETMC Tyler and be assured of receiving all the benefits offered” by their PPO plans, Elmer Ellis, president and CEO of the regional health care system, said in a statement.
The insurance company said in its own statement Thursday that it was looking forward to working with ETMC.
“We are mindful that our members count on us to provide access to care at the right place, at the right time and for the best value possible,” the statement said.
Neither side would comment on what led to the agreement.
ETMC also sued Aetna and Cigna in its original lawsuit.
The suit against Aetna was previously settled. The Cigna case is ongoing.
The health system’s outlying facilities have been in-network for years, which hospital officials said caused confusion for patients.
They also complained that if a patient needed to be transferred to the main hospital for specialized or complex care he or she would suddenly be shut out of in-network coverage.
The main hospital in Tyler offered the only kidney transplant option in the immediate area as well as the only Level I Trauma Center and deep-brain stimulation surgery for conditions such as Parkinson’s disease.
The case was highlighted by the Houston Chronicle in March as part of the continuing “Uncovered” series.