Triangle’s biggest pediatric practice stays with Blue Cross

Triangle’s largest pediatric practices reached a last-minute deal to be included in a key Blue Cross and Blue Shield health insurance plan, called Blue Value.

Jeffers, Mann & Artman faced the potential of angering or losing hundreds of families if their pediatricians were not covered by the state’s largest health insurer, an outcome that would have cost patients significantly higher out-of-network fees to see their doctor.

“We are pleased to inform you that we were able to come to a mutual agreement,” Jeffers, Mann said in an email to patients Wednesday. “We apologize that these lengthy negotiations have forced some of you to change your insurance plan or carrier.”

Blue Value is one of two networks that Blue Cross offers in Wake County to people who buy individual health insurance, most commonly through the federal exchange under the Affordable Care Act. The other Blue Cross network in the Triangle, Blue Local, includes WakeMed Health & Hospitals and Duke University Health System doctors, clinics and other facilities.

Enrollment for 2017 began Nov. 1 and health insurance coverage starts Jan. 1.

At issue for Jeffers, Mann was the amount of money Blue Cross would pay the doctors for medical services they provide to patients whom the insurer covers under Blue Value. An ongoing issue for Blue Cross is recouping ACA-related losses and controlling costs. The Durham insurer has said it lost $405 million on Affordable Care Act patients over two years, and raised rates 32.5 percent this year and another 24.3 percent for 2017.

“Our customers have been very vocal on their preference in choosing a smaller network of providers in exchange for lower premiums,” said Blue Cross spokeswoman Darcie Dearth. “We support any practice that puts a greater focus on the value of health care by providing a discount that our customers have come to expect.”

Jeffers, Mann told local families that Blue Cross was shifting costs beyond what the doctors could accept.

“Jeffers, Mann & Artman Pediatrics is being asked to take on risk and responsibility for payment of certain medical expenses that may be incurred outside of our practice in the course of your child’s care,” the practice said in a Dec. 14 email to patients. “We do not feel that we, as your physician, should take on a role that has traditionally been your and your insurance company’s responsibility.”

But for Jeffers, Mann, exclusion from the Blue Value network would have meant that its patients would have had to switch doctors or pay anywhere from an estimated 5 times to 10 times as much for out-of-network care at the practice.

Jeffers, Mann has five locations in the Triangle and 26 doctors as well as seven physicians assistants and nurse practitioners. Practice manager Debra Mann did not respond to a phone call Thursday.

This year Blue Value includes UNC Healthcare, UNC Rex Health Care and WakeMed, but in 2017 WakeMed will not be included for non-emergency visits because it failed to come to agreement with Blue Cross over contract terms. WakeMed is the only children’s hospital in Wake County so next year Blue Value patients will be limited to UNC Hospitals in Chapel Hill for in-network coverage.

WakeMed is advising patients on Blue Value this year to switch to Blue Local in 2017 if they want to remain covered in-network for non-emergency visits with WakeMed facilities and doctors. Emergency room visits to WakeMed will be covered on Blue Value in 2017.

Also not included on Blue Value in 2017 are some doctors associated with Key Physicians, a Wake County doctors’ network that negotiates insurance contracts and provides other services. Jeffers, Mann is part of Key Physicians but opted to negotiate with Blue Cross directly when talks broke down between the nonprofit insurer and Key Physicians.

Dearth said many Key doctors will continue on Blue Value. Key Physicians includes about 350 doctors, nurse practitioners and physicians assistants and about 250,000 patients, including an estimated 6,000 covered by Blue Value this year.

“A vast majority of doctors will remain in-network through Key Physicians on the Blue Value Plan,” Dearth said by email. “This means most members will be able to keep their doctor.”

This story was originally published December 22, 2016 at 6:06 PM with the headline "Triangle’s biggest pediatric practice stays with Blue Cross."