News

Oct 16, 2024

Congress could move the needle in Excellus talks with local healthcare providers

Negotiations between Excellus Blue Cross Blue Shield and major health care providers are still ongoing; an industry expert believes it may take congressional legislation to ease the financial burden

Negotiations between Excellus Blue Cross Blue Shield and major health care providers are still ongoing; an industry expert believes it may take congressional legislation to ease the financial burden on the health insurer to help get to a break through.

In August of 2023, the federal government announced nearly $1 billion was headed for Upstate New York hospitals after adjustments were made in how Medicare reimbursements are calculated. At the time, Sen. Chuck Schumer said it was a massive win for hospitals hemorrhaging money and staff following the hit of COVID-19. Hospitals saw this as a victory after making complaints about imbalance in care provided versus what hospitals actually received in Medicare.

However, insurance companies and non for profits are taking a hit. Excellus and similar insurance providers offer coverage through what’s called a Medicare Advantage Plan, which it does in tandem with the government. When adjustments were made to the Medicare formula, experts explain, insurers were suddenly on the hook for more money than they originally anticipated under the Medicare Advantage Plan.

“Health plans are especially in Upstate New York are feeling kind of up against the wall and that means they have to drive the hardest bargains they drive with providers,” Empire Center Senior Fellow Bill Hammond said.

Hammond is an industry expert with the think tank; he said that if legislation comes through to balance the scales with respect to the Medicare Advantage Plan, Excellus could be more willing to accept certain asks coming from St. Joseph’s Health or FamilyCare Medical Group.

“A lot of the resolution that people are looking for here will come out of Washington,” Hammond said.

Over the summer, Excellus’ CEO, Jim Reed, lauded an apparent effort from a bipartisan group of New York congressional representatives to address the issue, including Congressman Brandon Williams. So far, however, legislation on the matter does not exist and would be difficult without attaching itself to a “must pass” bill such as an Omnibus spending bill, according to Hammond.

The current deals at both Trinity Health, which operates St. Joe’s, and FamilyCare expire on Jan. 1. Excellus has maintained that the requests from the providers have been unreasonable; St. Joe’s and FamilyCare have independently stated that Excellus is failing to properly cover patients.

“While we continue to meet on a regular basis at this stage there is nothing new to report. We have not reached an agreement with Excellus. We will keep our patients informed about any progress. FamilyCare Medical Group’s position remains that quality care is not negotiable,” FamilyCare CEO Dr. Mitchell Brodey said in a statement on Tuesday.

In the meantime, both Excellus and WellNow Urgent Care have confirmed that negotiations are back on after the two failed to find an agreement coming into 2024, leaving people to pay out of network costs at the region’s sole urgent care chain.