Patients in insurance bind

For more than 25 years, Dr. Dennis Grollo has referred his patients to specialists and services at Condell Medical Center in Libertyville.

But now, the Libertyville physician is among 93 private doctors with admitting privileges solely at Condell who have been shut out of Blue Cross Blue Shield of Illinois' network since the health care insurer and hospital severed ties last week.

That places Blue Cross members who have long-standing relationships with those doctors in a bind to find "in-network" replacements, or accept lower insurance reimbursements for services.

Grollo expects he will likely lose some patients because of the change, though he doesn't believe it will put him out of business.

"I've had patients, some of them I've been seeing practically their whole life, and I don't want to disrupt their care," he said. "That's the most important thing. Condell has an extensive network so it made the continuity of care very easy for the patient and the doctors."

It is the latest twist in a year of bitter talks between the health care giants that culminated with last week's Cook County court ruling upholding Condell's decision to end its contract with Blue Cross.

At issue is the insurance company's decision to stop making roughly $1 million in weekly advance cash payments to Condell for patient services. Attorneys for the insurance firm said the decision was made because the hospital was asking for a higher rate of reimbursement than what was agreed in the contract.

An estimated tens of thousands of Blue Cross PPO and HMO patients will be reimbursed at "in-network" rates for services received at Condell: for PPO only through Oct. 31 and HMO through the end of the year. After that, members will receive benefits at a reduced, out-of-network rate and will be billed by Condell for the balance.

Blue Cross is asking doctors like Grollo to get admitting privileges at other hospitals by Nov. 2, if they want to be part of its network. Many doctors are starting to do that, company spokesman Tony Rau said.

The change will affect patients and doctors, Rau said, but had to be done.

"The contract specifies to be an in-network physician, you have to have admitting privileges to an in-network hospital," he said. "We obviously are trying to minimize the inconveniences as much as possible here."

Condell Vice President Jodi Levine said there was no need for Blue Cross to shut out the doctors.

"They have chosen to drag almost 100 very busy, popular physicians into this dispute by unilaterally terminating their contracts with Blue Cross; a move that will do nothing but hurt those independent physicians and the many, many patients they serve," Levine said. "It's a very significant financial blow to these physicians."

Rau said most of the physicians in Lake County have admitting privileges at more than one hospital.

"Others are exploring the possibility of referring patients to physicians with admitting privileges at network hospitals so patients won't face out-of-network charges after Oct. 31," he said.