SAN DIEGO (KGTV) – The start of the New Year is supposed to be about starting with a fresh slate.
For Lisa Schmidt, her year is starting as stressful as possible.
"Everything is so uncertain,” Schmidt said. "It's pretty scary, especially (for) someone who is having next week."
Stress because Scripps Health and Anthem Blue Cross were unable to work out a new contract. Lisa's worried her coverage is now out of network.
"I need care after that surgery. Everything's uncertain and it doesn't sit well with me,” Schmidt said.
The deadline for the two companies to get a deal done passed.
Scripps said there were issues with insurance red tape and what they describe as barriers to patient care.
While Anthem said Scripps demanded increased prices that would have led to major out-of-pocket costs.
We first spoke with Lisa, who's a Scripps patient insured by Anthem, last month as the two companies were negotiating.
She told ABC 10News she's dealt with a genetic condition for most of her life; causing long-term health issues and they got worse after contracting COVID-19.
"I just called UCSD because my referral went through neurology over there. So they're having to review to see if they'll take me which is scary right then and there. Like, I'm on treatment for severe migraines with a biologic,” Schmidt said
ABC 10News received statements from both Scripps and Anthem.
Both sides explain that while negotiations failed they remain open to having further discussions.
Anthem’s statement said, “Despite our good faith efforts to reach a new agreement, Scripps has chosen to leave Anthem’s local care provider network effective January 1, 2025. Scripps demanded drastically increased prices for patients covered by Anthem—increases that would have led to higher out of pocket costs for our members and would have hit area employers particularly hard. More than 80% of Anthem Blue Cross members are insured by employers that pay their employees’ healthcare costs directly.
Members currently receiving treatment for serious and complex conditions may be able to continue care with their current provider for a limited time. To do so, members or their doctors may contact our service center to request Continuity of Care accommodations. Anthem members also continue to have in-network access to several other high-quality partners throughout San Diego County who are prepared to provide care for members currently under Scripps, including UC San Diego Health, Sharp HealthCare, Palomar Medical Center and others.
We want Scripps doctors and facilities to return to our network and remain in active discussions to reach an agreement that offers affordable prices for the employers and consumers we serve. To stay updated, please visit anthem.com/ca/scrippshealth/ [anthem.com].”
Scripps said in its statement, “After many months of negotiation, the Scripps Health and Anthem Blue Cross contract terminated Jan. 1. The contract termination means Scripps has been removed from the Anthem network. All Anthem commercial insurance plans and individual Covered California plans are impacted. All providers and services across the Scripps system are impacted and no longer covered on an in-network basis by Anthem, with the exception of emergency care. Medicare supplemental plans are not affected.
Scripps proposed to continue negotiations beyond yesterday, but Anthem provided an ultimatum that was unacceptable. While Scripps remains open to finding a reasonable resolution, Scripps patients should contact their employer’s human resource departments to understand their health insurance options.
It’s important to know that everyone is always welcome at Scripps, regardless of what insurance plan or coverage they have. Emergency care is always considered in-network and is not impacted by this change. Anthem patients who want to continue seeing their trusted Scripps doctors and providers are welcome to continue doing so, too. However, patients are strongly encouraged to contact Anthem before receiving care at Scripps to learn how their coverage and out-of-pocket costs will change moving forward.
Scripps is notifying patients with Anthem coverage of the contract termination, educating them about their right to extended in-network coverage under continuity of care benefits for those who qualify, and ensuring they are aware of Anthem’s legal responsibility to continue to provide coverage for emergency care, without increasing patients’ out-of-pocket costs due to the out-of-network status.
Throughout the negotiation, Scripps’ focus was to change Anthem’s bureaucratic policies that cause unnecessary delays, burdens and barriers to patient care, while ensuring Scripps will receive fair and accurate payments for the high-quality care provided. It is disappointing Anthem was unwilling to reduce those barriers and offered rates below health care inflationary costs. Scripps’ costs are driven by factors such as the new health care minimum wage, escalating drug costs, unfunded government mandates and many other items.
The priority now is ensuring patients know that even though Scripps is out-of-network, they are still welcome here. In particular, no one in our community, including Anthem members, should consider an out-of-network status as a barrier to care during an emergency.
Employers who offer their employees insurance benefits through Anthem also are being notified of the contract termination. Organizations currently offering Anthem health care benefits may consider changing plans or adding an additional insurance plan option for those with employees requesting continued in-network coverage and access to Scripps Health.
More information and resources to support patients during this transition is available at scripps.org/anthem [link.mediaoutreach.meltwater.com].”
While they talk, people who need care have this message.
"Get your act together. There are patients that need care; tt's really a sad day for San Diego,” Schmidt said.
