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Reality Check: Why are Mission Health and Blue Cross Blue Shield at odds?

Only 42 days remain until Mission Health will be out of network with Blue Cross Blue Shield insurance. The sticking point in the contract negotiation is the rate Blue Cross pays Mission.  (Photo credit: WLOS staff)

Only 42 days remain until Mission Health will be out of network with Blue Cross Blue Shield insurance. The sticking point in the contract negotiation is the rate Blue Cross pays Mission.

Western Carolina University's Dr. Angela Dills specializes in health economics. She helps explain what's going on, starting with the few things Mission and Blue Cross agree on: They had months of negotiations, Mission asked for Blue Cross to pay more and neither side is conceding.

Mission CEO Dr. Ron Paulus says he doesn't want to leave the network but terminated the contract to incentivize Blue Cross to negotiate. BCBS says it doesn't negotiate when a party opts out. They each describe the contract they're negotiating as "evergreen" or "forever."

"My understanding of the way the prior contract was written is that when Oct. 5 comes through, that if they haven't negotiated a new contract, there's a default contract that's in place. That default contract wouldn't have a rate increase," said Dills.

In a recent Facebook Live, Paulus said Blue Cross offered a new contract with a lower reimbursement rate. So, his only only other option was to accept the automatic renewal with no change.

Blue Cross says it offered Mission a contract that allows for increases tied to quality and health outcomes.

"I kind of view it as two really big entities playing chicken with each other and seeing who's going to blink," said Dills.

Mission claims Blue Cross has raised premiums four straight years. A state Department of Insurance spokesperson says they couldn't confirm the claim, saying rate increases are confidential filings. Blue Cross did announce it has requested a 14 percent increase for premiums for 2018 plans available through the Affordable Care Act.

"Both Mission and Blue Cross Blue Shield are struggling to figure out how to make money, in part, because they're dealing with uncertainty over the federal government," said Dills.

Mission claims its prices are more than 20 percent lower than similar hospitals in the state. Blue Cross claims Mission charges the most in the area for some procedures, like CT scans.

"A lot of these reimbursement rates are propriety data," said Dills.

While the two sides talk about each other instead of to each other, Western North Carolina residents wait anxiously.

"This is one of the real struggles with health care in general. We the consumers, we the patients actually have very little voice in this process. If you're getting your insurance through your employer and they're the ones paying for your insurance, who is then paying for your health care provider? You're not really the customer for any of those players. So, it's actually, I think, really difficult for the consumers' voices to be heard," said Dills.

Paulus says he expects to reach an agreement with Blue Cross, but he said he doesn't know when. He said Blue Cross told him unless they reverse their decision to terminate the contract, they won't negotiate until after Oct. 5.

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