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BLOOMINGTON - Twenty-four of 28 Twin City specialists have rejoined the Blue Cross and Blue Shield of Illinois Preferred Provider Organization after leaving earlier this year over reimbursement rates and administrative hassles.

What this means for patients is renewed access to those physicians at lower in-network rates. How much lower depends on their insurance plan.

"We're very happy because our employees were concerned that they would need to drive out of town for some of their health care," said Laurie Wollrab, compensation and benefit manager for the City of Bloomington.

Tom Jecklin, manager of total rewards and benefits for State Farm Insurance Cos., said McLean County's largest employer also is pleased.

"It's good for our employees and good for the community," he said of the physicians' return.

When 28 specialists - including orthopedic surgeons, neurologists, urologists and general surgeons - left the Blue Cross Blue Shield PPO, patients were concerned about paying higher out-of-network fees, traveling for procedures and whether other doctors would join the 28.

Blue Cross has about 40,000 members in McLean County, said Tony Rau of Blue Cross and Blue Shield of Illinois, or about 62 percent of the local health insurance market excluding Medicare and Medicaid.

That number will increase Jan. 1 when many State Farm employees switch to Blue Cross, said Michael Hasselbring, president of the corporate benefits division of Clemens & Associates, the Bloomington-based insurance agency that represents a variety of health insurers, including Blue Cross.

But after several months, 24 of the 28 doctors are back in the network - many as recently as last week - for several reasons, including:

• Being out-of-network was affecting the physician-patient relationship.

Dr. Jeffrey Poulter, plastic surgeon with The Center for Cosmetic and Laser Surgery in Bloomington, said one breast reconstruction patient said she'd switch to an in-network plastic surgeon for follow-up care, even though her surgery by Poulter was successful and he had assured her his out-of-network fees were only slightly higher than in-network fees.

"That kind of sealed it for me," he said. "I want to take care of my patients."

• Administrative relief didn't come.

In August, doctors and practice managers said administrative hassles with Blue Cross - such as not paying claims in full but without explanation, re-coding procedures to reflect simpler and less expensive surgeries, and not getting questions answered - made dealing with Blue Cross difficult.

But being out-of-network carried its own frustrations. Information that had been transmitted electronically for in-network offices came by paper out-of-network, increasing staff work, said Gregg Chadwick, administrator of Orthopedic & Sports Medicine Center in Normal.

Also, some administrative burdens switched from office staff to patients, Chadwick said, resulting in frustration for patients, who then had additional questions for the staff.

"Our experience out-of-network was that it was very confusing for the patients," Chadwick said. "In the end, it came down to deciding that it (remaining out of network) wasn't worth the inconvenience that it was causing patients."

• Doctors realized there wouldn't be movement on reimbursement.

Doctors said in August their reimbursements for procedures is decided unilaterally by Blue Cross and reimbursement levels are low. But in subsequent meetings to resolve the dispute, employers made it clear they wouldn't discuss payment issues.

"Employer groups weren't in favor of fee reimbursement increases," Hasselbring said. "Everybody is very concerned about health care costs."

Doctors were disappointed. Their position was weakened further when no other physicians joined them and it became clear more employers would switch to Blue Cross on Jan. 1, said John Hesse, executive administrator of the McLean Area Medical Association. That meant the 28 wouldn't have in-network access to those people.

In November, some of the doctors began to rejoin the network. That got the attention of the others - and their competitors, Hesse said.

• Blue Cross agreed to address administrative issues.

During the meetings, the employers' role was to encourage Blue Cross and physicians to resolve their administrative issues so the stability of the network could be re-established, Jecklin said.

Physicians and their staffs expressed their concerns. Blue Cross recognized the need to increase training of doctors' office staffs regarding coding and claims processing and agreed to look into having a provider relations staff person in McLean County to work with staffs, Rau said.

"The communication is better," Chadwick said. "I feel like we got answers to some of our questions about the way Blue Cross processes and pays claims."

Poulter said he is hopeful the discussions will be ongoing.

"I'm confident that the employers in town who are using Blue Cross will make sure the administrative burdens will be addressed," Poulter said.

"The progress shouldn't stop here," added Jecklin. Wollrab agreed: "It's important to keep this going."


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