When Coverage Breaks Down: The Hidden Costs of Insurance Disputes

In this episode of The Vitals, we sit down with Dr. Alan Adler to unpack one of the most important issues affecting patients and health systems today: negotiations between hospitals and insurance companies. 

As discussions continue between Mount Sinai and Anthem, Dr. Adler explains what is at stake in these conversations, how contract negotiations between major health systems and insurers typically work, and why these agreements can have far-reaching implications for patient access, affordability, and continuity of care. 

The conversation also explores the broader economics behind hospital-insurer relationships—how reimbursement rates are determined, what drives negotiating leverage on both sides, and how health systems balance financial sustainability with their commitment to patient care. 

📅 To learn more about Mount Sinai services or schedule an appointment with a provider, visit Mount Sinai online today: https://www.mountsinai.org/?pk_vid=174eeee090819798177342044977c34c

🎧 Subscribe to The Vitals and explore more podcast programming from Mount Sinai for expert conversations on the biggest issues in medicine, research, and patient care: https://www.youtube.com/playlist?list=PLCT7BA-HcHliU8QIXyuk_74L_uH0gyKGt

Transcript

00:00:00:01 - 00:00:27:03

Leslie Schlachter

Hello and welcome back to the vitals, the Mount Sinai Health System's groundbreaking roundtable video podcast. I'm your host, Leslie Schlatter, a neurosurgery physician assistant, here at the Mount Sinai Hospital. On this special edition of our show, we're going to discuss the role of insurance companies in health care and in hospital systems like ours. Specifically, we're going to delve into the ongoing negotiations between Mount Sinai and Anthem Blue Cross Blue Shield to walk us through the facts on the ground.

00:00:27:04 - 00:00:44:16

Leslie Schlachter

We're joined by Doctor Alan Adler, a practicing ObGyn here at the Mount Sinai Hospital, and he's also the senior director for physician contracting and billing. Doctor Adler, thanks for being here. Let's get this started.

00:00:44:18 - 00:01:02:28

Leslie Schlachter

How did we get here? Like I, I want the listeners to know because, like, I'm sure there's a lot of people listening that have anthem. And for someone who practices, I see dozens of patients every week. We operate on patients with anthem, and I'm losing my like, I'm losing my patients. I'm losing my patients and my patients. Absolutely.

00:01:02:28 - 00:01:16:13

Leslie Schlachter

Because I have I have a right now I have a patient on my schedule for the first week of April. We've tried to get a continuity of care. We can't. I have to move the surgery up. I have to move things around. This is so chaotic. How did we get here?

00:01:16:16 - 00:01:35:15

Dr. Alan Adler

So in a nutshell, we try to engage anthem, you know, in specific. And then we had other negotiations with all of three other majors, and we were able to come to agreements over the past two years. Anthem. We knew that the contract ended December 31st, so we tried to engage them. June they were not engaged without.

00:01:35:16 - 00:01:38:25

Leslie Schlachter

Meeting engage outside of just like your normal monthly one hour meetings.

00:01:38:28 - 00:01:59:29

Dr. Alan Adler

No, our contracting team tried to engage them to develop a new contract before it expires December 31st. They would not agree to meet with us. We started to meet with them in August, and we made some headway until about Thanksgiving. At Thanksgiving, they inexplicably just said, we're not doing anything we agreed to and we're not talking to you anymore.

00:01:59:29 - 00:02:03:17

Dr. Alan Adler

And they just had no negotiations through the end of the year in the contract. So you.

00:02:03:17 - 00:02:04:13

Leslie Schlachter

Guys got ghosted by.

00:02:04:13 - 00:02:05:17

Dr. Alan Adler

Anthem, basically.

00:02:05:18 - 00:02:22:20

Leslie Schlachter

And I like take a couple steps back because I know there's like so much I want to ask you that I probably can and there's probably a lot you want to say, but I know you can't say. And ultimately we want this deal to go through. Let's talk about just the basics. What are renegotiating. So there's a contract.

00:02:22:20 - 00:02:29:25

Leslie Schlachter

What's a contract? We provide a service. We agree that they're going to pay us X. What else goes into the contract.

00:02:29:28 - 00:02:38:01

Dr. Alan Adler

So much more than that right. So the rates are the one thing. And you know one of the things that everyone should know I don't know who's listening to this podcast. If it's patients.

00:02:38:02 - 00:02:39:00

Leslie Schlachter

Everyone's going to be like oh.

00:02:39:07 - 00:02:47:13

Dr. Alan Adler

Well that's good. So then they can know, so we are the lowest paid, excellent health care system in New York City.

00:02:47:20 - 00:02:50:06

Leslie Schlachter

How did we let that happen? Why did we agree to that in the first place?

00:02:50:06 - 00:03:10:14

Dr. Alan Adler

So it started way back when. Before any of us that are involved in the negotiations now we're we're involved. You know, back 25, 30 years ago when managed care was more in its infancy, Mount Sinai did not was not aggressive in terms of the getting the rates for both their providers and also for the hospital. So there are two different sets of rates.

00:03:10:14 - 00:03:16:17

Dr. Alan Adler

There is a rate for the facility, which is the hospital, and there's a professional rate, which is the providers.

00:03:16:17 - 00:03:28:18

Leslie Schlachter

So let's use your services. You charge X for to do a C-section. The hospital also provides services. They have to charge y. So X and Y were negotiated 25 years ago.

00:03:28:20 - 00:03:52:04

Dr. Alan Adler

And changed over the years. But since we started so low, we've never caught up to the other health care systems, you know, in New York City. And everyone knows that, including anthem. We couldn't prove it for many years. But there's a new transparency laws that came about from the government in the last couple of years. So now we know we can prove exactly what we're getting versus, you know, everyone else in New York.

00:03:52:07 - 00:03:59:15

Leslie Schlachter

So basically, we're paying $50 an hour for babysitting services when all the neighbors are only playing 20 kind of.

00:03:59:18 - 00:04:13:12

Dr. Alan Adler

Well, so and what people don't understand, you know, as patients is they think, first of all, that everything is covered, right? So they think that you go to the doctor and it's covered. They forget that there's something called co-insurance is an in-network deductibles.

00:04:13:13 - 00:04:16:23

Leslie Schlachter

Well, every January they forget about their deductible I know this.

00:04:16:26 - 00:04:40:00

Dr. Alan Adler

So you know, patients come to us to Mount Sinai. They're actually paying less than if are, you know, if it is an in-network deductible or a coinsurance. Because we have a lower contracted rate, they will pay us less. They will always loss. And that's you know, anthem knows that. And even with the increases that we've asked for, we will still be lower than most of the health care system.

00:04:40:00 - 00:05:01:21

Dr. Alan Adler

So we're not asking for anything exorbitant. But more than that, there's also contract language that has to be put in. So currently, anthem mount Sinai, hundreds of millions of dollars because of denials that were not, you know, legal. Because it take backs that they shouldn't have taken back. In addition, they to take back. So I'll give you an example.

00:05:01:23 - 00:05:08:29

Dr. Alan Adler

I did a delivery in 2022. Anthem waited more than two years to take the money back, which they're not.

00:05:08:29 - 00:05:10:05

Leslie Schlachter

Why would you take it back?

00:05:10:08 - 00:05:23:22

Dr. Alan Adler

They. There was some glitch in the billing, but they didn't have the right to take it back. So at this monthly meeting I brought up, you know, you do not have the right they acknowledged that they did not have the right to take it back. And I said, okay, reprocessing.

00:05:23:24 - 00:05:24:23

Leslie Schlachter

Would take back take back.

00:05:24:29 - 00:05:41:07

Dr. Alan Adler

What we were trying. So first they said that it belongs to a blue card program, which is an out of state plan. They said they have no control of it. What they're doing in their network, you know, Blue Cross of Illinois or Blue Cross of California. They said they have no control over what they do, yet they're part of their network.

00:05:41:09 - 00:05:59:29

Dr. Alan Adler

Then they said they were part of the J card program and they have no control over that. Then they said, this is this is the best line I've heard in years. The one person in anthem that could cut the check to us was on maternity leave. So this multibillion dollar company had one person that can cut a check and that was a year ago.

00:06:00:00 - 00:06:23:17

Leslie Schlachter

I mean, it's just sounds like insurance companies. It smells is like very in line with their personality. So I feel like we just keep opening up parentheses and we're never going to actually close one. But let's just be super clear. Let's define a couple things. There's deductible. There's what's covered. There's co-insurance. Then you can have other insurance. So like let's just say patient goes to hospital for a procedure.

00:06:23:17 - 00:06:50:23

Leslie Schlachter

I'm not even going to call it something. It's $100,000. Everything. The doctor the hospital I don't know what procedure that is. $100,000. It is January 5th. They haven't met their deductible. Their deductible is $5,000. All right, so a $100,000 bill. The patient is responsible for the $5,000 first. Correct. So let's say their insurance let's call it anthem, is going to pay for 70% of what they deem to be appropriate and reasonable.

00:06:50:28 - 00:07:14:01

Leslie Schlachter

So our fee schedule, which means the agreed upon amount that they said that they were going to pay, let's say that that's $50,000, which is sad, but let's just say that's the case. So they're going to pay us $50,000. Speaking from my own experience, sometimes the check will come through for $20,000. So that means either a we then have to go after the patient for the remaining amount.

00:07:14:03 - 00:07:20:14

Leslie Schlachter

Co-insurance. So 75,000 to 35 $65,000. What did I say 25 or 35.

00:07:20:16 - 00:07:24:20

Dr. Alan Adler

Well we're only supposed to get 50 and they paid 30 or 20.

00:07:24:27 - 00:07:48:02

Leslie Schlachter

All right. So we'll even bring it down. So we're going to go after them for that remaining $15,000, whatever it was. What patients don't realize is insurance coverage means that they may not pay the full bill. They're responsible for the co-insurance, but oftentimes we have to wipe that amount because the patient can't pay it. And we're just we're double losing on what our costs are.

00:07:48:04 - 00:07:49:08

Leslie Schlachter

What did I miss?

00:07:49:10 - 00:08:01:16

Dr. Alan Adler

You didn't miss anything. I mean, you know, hopefully we can work out an arrangement with the patient. But if the patient really has a hardship, I mean, Mount Sinai, you know, works with patients to try to get, you know, what they can afford.

00:08:01:18 - 00:08:19:17

Leslie Schlachter

But but the point of that is to prove, like when patients are frustrated about their coverage, we have to keep our doors open. We have to pay for garbage to be like products coming in, garbage coming out pays doctors, nurses. Everything here costs money. So if we're not making money off of our services, we're not going to keep doing this.

00:08:19:21 - 00:08:29:11

Dr. Alan Adler

Well, that's why we need to get rate increases, right? So even though, you know, anthem may write whatever they're writing in there, you know, a website, but basically where.

00:08:29:12 - 00:08:48:06

Leslie Schlachter

I have it right here, I'm sure. Adler so they're saying basically what was we obviously want an increase in our fee schedules across the board for all of our departments. The rates that we are asking for them to reimburse us, are they on par with the other hospitals in New York City?

00:08:48:09 - 00:09:11:22

Dr. Alan Adler

So what I think is misleading is it's not the actual rate increase because we're starting out so much lower, like if we're 35% below a certain other health care system, even if our rate increase would be 2% more, we're still well behind them. So they're focusing on the actual rate increase. They're not focusing on the overall picture. So that's how it's misleading what they're telling the public.

00:09:11:24 - 00:09:20:25

Leslie Schlachter

So what. So back to the question the what we're asking for them to reimburse us. Is it the same less or more than other hospitals in New York area?

00:09:20:26 - 00:09:25:07

Dr. Alan Adler

It will still be less even with the increases. Right. Because so they catch up in one.

00:09:25:07 - 00:09:26:08

Leslie Schlachter

Well why not like.

00:09:26:11 - 00:09:35:14

Dr. Alan Adler

What's the holdup? They're not going to do that, right? There's no way that they're going to agree to that. And we understand that. So that's why we're not asking for double digit increases. We're asking for single digits.

00:09:35:16 - 00:09:38:03

Leslie Schlachter

So why won't they give the single like why.

00:09:38:04 - 00:10:00:08

Dr. Alan Adler

That's a great question and one that we would love to ask. Anthem. So we actually they did reengage. You know, we had talked about how they did not engage. And then in January they came back with where they were in August. So not really anywhere, even where they were in November. And then right before the hospital is now out of network as of last night, midnight.

00:10:00:10 - 00:10:09:05

Dr. Alan Adler

They did engage with us for several days. On Friday we had the basis for an agreement both on rates and on most of the language.

00:10:09:07 - 00:10:11:07

Leslie Schlachter

Yeah. You know, get into the language.

00:10:11:13 - 00:10:17:00

Dr. Alan Adler

And then they, they would you know we nag the next day less than 24 hours later.

00:10:17:02 - 00:10:31:05

Leslie Schlachter

So it's not just like the fee schedule. There is something here about removing contractual safeguards. So just for the viewers this is on anthem website. It's basically their.

00:10:31:10 - 00:10:31:27

Dr. Alan Adler

Version.

00:10:31:27 - 00:10:39:23

Leslie Schlachter

Version press release. I don't know, it made me very, very upset. I got very I'm not even involved in this process and I'm very upset by this.

00:10:39:23 - 00:10:55:05

Dr. Alan Adler

Well, everyone's really upset by it because it's, you know, if they would engage with us fairly, I mean, and do the contract language, there were two, requirements that they had in terms of the contract language, which we agreed to. And what they're saying is actually not true.

00:10:55:08 - 00:11:11:20

Leslie Schlachter

So Mount Sinai saw additional charges. Sorry. Mount Sinai saw additional changes on how employer sponsored health coverage operates, including removing contractual safeguards that help protect patients and employers from billing errors and unnecessary costs. What the heck did that mean?

00:11:11:22 - 00:11:12:10

Dr. Alan Adler

I'm not really.

00:11:12:10 - 00:11:13:26

Leslie Schlachter

Sure. I think that means.

00:11:13:28 - 00:11:21:19

Dr. Alan Adler

It's just mumbo jumbo. And we we basically, you know, we need contract language to to protect our patients, right?

00:11:21:19 - 00:11:23:00

Leslie Schlachter

So contract language are you looking at it.

00:11:23:00 - 00:11:37:29

Dr. Alan Adler

So we're looking to try to avoid these denials. Right. That and the take backs that led to us demoing us hundreds of millions of dollars. And when they do this take back or they do a denial, who's responsible for it?

00:11:37:29 - 00:11:41:12

Leslie Schlachter

Eventual patient. Right. Or we have to write it off and we just keep losing money.

00:11:41:17 - 00:11:48:17

Dr. Alan Adler

Right. So, you know, it's unfair and we're trying to protect our patients at Sinai. As you know, the patients always come first.

00:11:48:17 - 00:12:12:14

Leslie Schlachter

Right? So let's throw a couple fun things in there. So let's say okay. So it's patients listening. And they're like what the heck. All my doctors at Mount Sinai, what can I do? Well, there's a couple of things. So there's seeing your provider for like, you know, check ins, imaging, maybe just even just like a chat so patients can still pay out of pocket to see the doctor they want to see.

00:12:12:22 - 00:12:25:16

Leslie Schlachter

So each doctor or PA because myself I have my own fee schedule for services. You can contact the provider's office and say how much would it cost for me to see my provider out of pocket? That's reasonable. So they can do that?

00:12:25:23 - 00:12:29:26

Dr. Alan Adler

They absolutely can. Plus, some people are eligible for continuity of care.

00:12:29:27 - 00:12:46:04

Leslie Schlachter

Now let's talk about continuity of care. So continuity of care basically you call your insurance company, you call anthem and you say I'm a mount Sinai patient, I'm going to be out of network. I'd like to complete a continuity of care form, which typically gives them like three months.

00:12:46:06 - 00:12:51:21

Dr. Alan Adler

So yes, it's 90 days for most conditions, but there are certain conditions that extend beyond the 90 days. Right.

00:12:51:25 - 00:12:53:10

Leslie Schlachter

Like which is their website.

00:12:53:10 - 00:12:53:26

Dr. Alan Adler

Yeah. Yeah.

00:12:53:27 - 00:12:56:16

Leslie Schlachter

Oncology or like a previously scheduled surgery or something.

00:12:56:21 - 00:13:00:01

Dr. Alan Adler

Or, you know, cancer, pregnancy transplant.

00:13:00:03 - 00:13:08:28

Leslie Schlachter

Now here's the thing. If you did your continuity of care too soon, like let's say you had a freak out in July, you might not get an extension for that continuity of care.

00:13:09:04 - 00:13:18:12

Dr. Alan Adler

So some somewhat we weren't out of network. So it doesn't start till January 1st. So the 90 days start when we were out of network.

00:13:18:14 - 00:13:21:12

Leslie Schlachter

That is not true. That is not what my patients are being told.

00:13:21:16 - 00:13:22:16

Dr. Alan Adler

Then that's the.

00:13:22:16 - 00:13:44:28

Leslie Schlachter

Problem. That's the problem. So I currently have a patient right now who's scheduled for surgery first week of April. They requested their continuity of care form when we like. They knew this was happening. They requested it so their last day would be like their 30 days and like second week of March. And so we just asked them to like at least complete it for.

00:13:44:28 - 00:13:53:03

Leslie Schlachter

And they won't they won't they refuse to to extend their continuity of care to cover their surgery. So now I have to move the surgery up to the first week like.

00:13:53:03 - 00:14:14:28

Dr. Alan Adler

That, so that makes no sense. And then you should escalate that. We have a team that works on that. But the problem is this. So other insurance companies had us meet with their medical directors for about continuity of care, right months before we were out in network, just in case. And anthem would not allow their medical directors to meet with us until two weeks after we were already out of network.

00:14:15:01 - 00:14:27:07

Dr. Alan Adler

And, you know, they told us things then and, you know, they said, you know, this is true and this is true. And then our patients are finding when they call the front line people in anthem, they're being told totally different things.

00:14:27:09 - 00:14:30:27

Leslie Schlachter

Yeah. One patient, I mean, my patients are being told random things.

00:14:30:29 - 00:14:44:29

Dr. Alan Adler

It's crazy. I have my niece has something call you know, has anthem but fully insured. So fully insured as per the medical directors was supposed to run till March 31st, as long as she was seen somewhere in Mount Sinai ambulatory.

00:14:45:04 - 00:14:48:18

Leslie Schlachter

But you have to have established care to have continuity of care. Right.

00:14:48:21 - 00:15:12:02

Dr. Alan Adler

And you know, when the she wanted to just to get a primary care doc, which was totally fine. The primary care doc department called anthem and they were told out in network and she couldn't be seen. So I had to get involved and say, yes, she could be seen because this war was horrible. So why is the front line desk, you know, telling people this number one anthem is so large and they're not communicating well?

00:15:12:09 - 00:15:17:24

Dr. Alan Adler

Or are they doing this deliberately just to cause confusion? Your guess is as good as mine, right?

00:15:17:26 - 00:15:38:07

Leslie Schlachter

So let's say patient has like right now the continuity of care and the coverage is good until March 31st. Right. So let's say a patient I have a patient I'll come up with an example. I actually have someone I'm thinking about. I have a patient who I have on surveillance for a brain tumor who's been having seizures.

00:15:38:09 - 00:15:55:12

Leslie Schlachter

The goal is for this person to get seizure control over the next couple months, and then take the patient to surgery once their brain is calm and they've been controlled, that's now very stressful because they're going to be out of network. All right. Let's say that patient loves us so much they don't want to go somewhere else. They have a seizure at home.

00:15:55:12 - 00:16:03:24

Leslie Schlachter

They're altered. They come through the E.R. we can then operate on them. We can take care of that because it's an emergency. And then we'll get reimbursed at in-network rates.

00:16:03:24 - 00:16:27:27

Dr. Alan Adler

So the rules for the E.R., because there are federal and state regulations is anything that goes through the E.R. is covered, as you just said. Yeah. So the E.R. visit is covered. Any procedure, any diagnosed diagnostic procedure, any surgery, and even the follow up in the ambulatory setting from that E.R. visit is covered. What the rate exactly is, is not necessarily what anthem would pay in 2025.

00:16:27:27 - 00:16:38:21

Dr. Alan Adler

So continuity of care. They should pay what our contracted rate was for 2025. There are different rates when people come through the E.R.. So I don't.

00:16:38:21 - 00:16:40:23

Leslie Schlachter

So how do you like audit that process?

00:16:40:25 - 00:16:58:09

Dr. Alan Adler

You know, you just got to, you know, see it in each department. So the E.R. department is going to do it. If you do surgery, you'll see what you get on that patient. But yes, it is it is chaotic. And we don't want to have to do that. I mean, the goal here is to come to an agreement.

00:16:58:12 - 00:17:23:08

Leslie Schlachter

I thought we were going to come to an agreement before this happened. I really thought this was going to be like one of those, like last night, like end to the end of the road decisions. It's like shocking. It hasn't. So what does the after March 31st actually mean for anthem patients who are supposed to get their colonoscopies and their mammograms and supposed to they have appointments scheduled through the first six months, like what happens.

00:17:23:11 - 00:17:57:02

Dr. Alan Adler

So they can pay out of pocket. They can use their out of network benefits, you know, self-pay, if they're not eligible for continuity of care, remember those? There was a special continuation of coverage for certain plans, like the New York State regulated plan. So, fully insured patients like my niece or New York State Medicaid, child Health plus family health, plus the essential plans and even the exchange plan, which we are no longer going to be part of moving forward, had a special extension, which we learned through the medical directors from anthem.

00:17:57:06 - 00:18:15:21

Dr. Alan Adler

So those patients were covered from March 31st. But now if they didn't, we weren't eligible for, let's say, for a mammogram because they had one in May and they want to do it in May. And if we're not back in network by May, then they, you know, we have to use their out of network benefits or go somewhere else.

00:18:15:23 - 00:18:25:02

Leslie Schlachter

So what do you want? Like what's the bottom line. You want patients to know as to like because they feel like this is happening to them. Like what do you want them to know?

00:18:25:05 - 00:18:43:07

Dr. Alan Adler

So I want them to know that this is not Mount Sinai that we tried we tried to get them to the table to negotiate fairly, and in fact, like I said, we got even last weekend. We were poised to have a deal before they reneged on it. And it's not about the rates because we we agreed to the rates.

00:18:43:07 - 00:18:57:17

Dr. Alan Adler

We were even close to the rates in back in round Thanksgiving. It has to do with the contract language and we have to protect our institution. We have to protect our providers. We have to protect our patients so that contract language is important for all of those people.

00:18:57:19 - 00:19:02:19

Leslie Schlachter

So is are they just swimming in so much money that they don't need us anymore?

00:19:02:21 - 00:19:21:11

Dr. Alan Adler

I think they need us. Right. So we're talking about, you know, 225,000 patients that use Mount Sinai. We're talking about 9000 providers. Right. So we are here, you know, we provide excellent care. Our patients are really irate about this, and our physicians are irate.

00:19:21:13 - 00:19:31:15

Leslie Schlachter

What does this mean? So like, these people live in this area. So what does that mean for the hospitals that do take it. They're just going to get overrun and then care is actually going to decrease because they're not gonna be able to keep.

00:19:31:15 - 00:19:49:23

Dr. Alan Adler

Up even more than that. Right. So they are if they go to another hospital, it's going to cost somebody more money, right? So if they're fully insured, it's going to cost anthem more money. If they're self-insured, it's going to cost all the employers, all the clients of anthem more money. Right. Because they're the ones footing the bill.

00:19:49:26 - 00:20:05:12

Dr. Alan Adler

And if they have high deductibles or coinsurance, it's going to cost the patient more money. So not only me, they have lesser care because the hospitals are overrun and can accommodate them, but it's also going to cost more. So this is totally illogical. What anthem is doing.

00:20:05:14 - 00:20:23:10

Leslie Schlachter

What are some of the other things that were problematic? I mean, I know where they are, I live them, but like do what did people have complaints about anthem with regard to like getting things? Is it like just getting scans covered? Was it getting surgeries, procedures? Was it just like denials also.

00:20:23:10 - 00:20:44:18

Dr. Alan Adler

Yeah, it's it was denials of care. Right. And it's not getting authorizations. I'll give you an example. Just from my practice, we, you know, have OB patients. All of them require a genetic carrier screen. Right. You have to know that the two people are not carriers for the same disease. Anthem never covers it. They just deny it and for no reason.

00:20:44:18 - 00:20:51:29

Dr. Alan Adler

This is a medically necessary test. And the lab fights it. We were furnished letters and they still don't cover it. And the patient has to pay the level that.

00:20:51:29 - 00:20:53:20

Leslie Schlachter

Covered at other hospitals.

00:20:53:22 - 00:20:56:05

Dr. Alan Adler

Covered at other insurance companies?

00:20:56:07 - 00:20:59:24

Leslie Schlachter

No. Does anthem cover those services either?

00:21:00:00 - 00:21:00:20

Dr. Alan Adler

Yeah, we don't know that.

00:21:00:20 - 00:21:13:26

Leslie Schlachter

Okay. So it's not just reimbursement. It's language to avoid things like take backs. And it's actually getting authorization for things that you as provider say that you need for the health and safety of your patients. Right.

00:21:13:26 - 00:21:14:28

Dr. Alan Adler

Try to get an MRI.

00:21:14:28 - 00:21:34:02

Leslie Schlachter

It's like I mean, hi, that is really hard. Yeah. For our listeners, when we ordered a test for someone like, let's say you come in, you're having headaches, we think something might be wrong. I want to order an MRI or a Cat scan or something. Typically, the insurance company would be like, nope, prove it. They're hoping that I didn't really mean it.

00:21:34:02 - 00:21:51:20

Leslie Schlachter

I didn't really want the test and I'm not going to call. So we call, we get we try and get an authorization. We give them medical information. They still say no. Then you can request something called a peer to peer, which means the provider, the ordering person, which usually in my case, it's me. We schedule a time speak to a medical director at the insurance company.

00:21:51:20 - 00:22:15:06

Leslie Schlachter

There's a whole bunch of doctors that work as medical directors at insurance companies. You tell them what's going on with your patient and you advocate for them. Now the merger here's the sad part is, like for me in neurosurgery, no one's really going to say no to my request. Like, if somebody has a brain tumor, I get on the phone, I wait for like 15, 20 minutes, I get on the phone and then I have a 45 second conversation and it's approved.

00:22:15:08 - 00:22:21:07

Leslie Schlachter

That whole rigmarole, all the overhead it took to get there, it's totally unnecessary.

00:22:21:10 - 00:22:26:16

Dr. Alan Adler

Absolutely. But you at least got approved. Yeah, many of our providers have to do all that and.

00:22:26:16 - 00:22:31:08

Leslie Schlachter

Then it doesn't get approved down. I get turned down like 2 or 3 times a year. But I think it's my specialty.

00:22:31:10 - 00:22:38:02

Dr. Alan Adler

No, I understand that right. I mean, it's just so unfortunate and it's it's it's terrible for the providers and it's terrible for the patients.

00:22:38:04 - 00:23:04:04

Leslie Schlachter

Yeah. And then another, another one is like we for neurosurgery. There's every time you when you schedule someone for surgery, there's codes that go into the surgery. So for us there's approaching a tumor, rejecting a tumor, using the microscope, using navigation, maybe doing a fat graft or something. All of those are codes. All of those have, a reimbursement rate on the fee schedule.

00:23:04:04 - 00:23:23:16

Leslie Schlachter

So you call the insurance ahead of time, you say, hey, Joe Smith has a brain tumor, we're going to use these codes for surgery. And the insurance company will say yes, no, yes. No, no. Then you're supposed to say what, like I I'm sorry. We're supposed to do brain surgery at a third of the price because you won't approve the code that we need to.

00:23:23:16 - 00:23:26:01

Leslie Schlachter

Actually. No, no.

00:23:26:04 - 00:23:30:25

Dr. Alan Adler

It's it's mind boggling. And it really is. And some insurance companies are worse than others to deal with.

00:23:30:27 - 00:23:37:21

Leslie Schlachter

Yeah. Was it wasn't there a story about someone like a surgeon who actually got a call during surgery that something wasn't approved?

00:23:37:23 - 00:23:46:20

Dr. Alan Adler

Yeah, in the middle of a brain surgery. I had heard that, you know, they called up and said they're only approving one side of the brain. I mean, how can you do that in the middle of a surgery? It's just crazy.

00:23:46:23 - 00:23:58:25

Leslie Schlachter

It's insane. So how do we recover from this? Like, what do you, from your personal experience, what do you think is going to happen?

00:23:58:27 - 00:24:19:13

Dr. Alan Adler

You know, I don't know, right? I mean, we have been there, ready to engage, and we we thought we had a deal or close to a deal several times, only to have it pulled back. So, you know, we we don't know what Anthem's motivation is here. Now, the hospital is out of network as well. You know, all the facilities, all the article 28 sites.

00:24:19:16 - 00:24:35:05

Dr. Alan Adler

I mean, patients are very, very upset. The doctors are very upset. You know, we hope that they will come to the table to negotiate a fair deal. That's all we're asking for. We're not asking. We're asking for things that they already agreed to before they reject.

00:24:35:08 - 00:24:52:23

Leslie Schlachter

So even if a patient wanted to pay self-pay to, like, see their provider. So let's say, all right, you're going to keep seeing me as your provider. I can send you to lab core for your labs. I can send you to X radiology facility to get your scans. You'll then bring that to me. We'll see you and you can pay out of pocket for that.

00:24:52:27 - 00:25:01:19

Leslie Schlachter

But if I need to do a procedure on that patient or schedule something in the hospital, that's not really an option for most people to self-pay a couple hundred thousand dollars.

00:25:01:22 - 00:25:22:12

Dr. Alan Adler

Absolutely not. It's you know, and that's why, you know, again, this is so unfortunate. And I feel the worst for our patients. But I also feel the worst. You know, I feel terrible for our providers. I mean, I've had patients that I've been caring for for 30 years that have anthem, and now they have to decide whether they're going to see me, even for their annual.

00:25:22:12 - 00:25:25:19

Dr. Alan Adler

And it's nothing like having brain surgery.

00:25:25:21 - 00:25:41:05

Leslie Schlachter

I would definitely pay out of pocket to see you for my annual, so just to kind of go further into this, like, is there how does that conversation is there a mediator? Do you guys pay like a third party mediator to talk to you guys, or do you guys just like both parties come together and try and talk?

00:25:41:08 - 00:25:41:25

Leslie Schlachter

How does it work.

00:25:41:25 - 00:25:47:08

Dr. Alan Adler

So we have a contracting team. Okay. Anthem has their contracting team.

00:25:47:10 - 00:25:49:20

Leslie Schlachter

What is a contracting team like? Like a mediator?

00:25:49:22 - 00:26:07:12

Dr. Alan Adler

No, it's just people that work. For most people that work for anthem. There's legal involved and there and there's the, you know, the math people, right? The accountants and figuring out what these deals are worth and, you know, people to put together the language that we need to make this doable.

00:26:07:12 - 00:26:13:04

Leslie Schlachter

So there's probably people on both sides that have their numbers, and it's just probably coming down to numbers. It's a numbers game, everything.

00:26:13:05 - 00:26:29:11

Dr. Alan Adler

So again, you know I don't think the rates are really the issue. I mean, they may say that we're asking for astronomical things and that's clearly not true. They know it's not true. But you know, they've agreed to much of the language and then they the next day, like I said, they just walk it back.

00:26:29:13 - 00:26:33:10

Leslie Schlachter

So, you know, the mediator be helpful. Do people do that and stuff like this.

00:26:33:13 - 00:26:46:05

Dr. Alan Adler

You know, I you know I haven't seen that happen. And with the negotiations I mean there are is arbitration for things that let's say the insurance company owes you lots of money. You go to an arbitrator, but that takes a long, long time.

00:26:46:05 - 00:26:48:13

Leslie Schlachter

Is Mount Sinai for profit or not for profit.

00:26:48:15 - 00:26:48:29

Dr. Alan Adler

Not for.

00:26:48:29 - 00:26:57:25

Leslie Schlachter

Profit. Okay. So like how does that concept of what does that mean. Profit. Not for profit. And how does it relate to the insurance and how it relates to patients.

00:26:57:25 - 00:27:17:18

Dr. Alan Adler

So look at it this way. Right. So we're not profit organization and any any money that we make. It's funneled back into the system. And you know for things that we have to provide better care. Right. So just look at the nursing strike that just happened and the nurses got an increase. We have to cover that we hope to cover.

00:27:17:21 - 00:27:41:05

Dr. Alan Adler

Increases. If you're bringing a specialist on, you know, that you want to start a new department or something. You know, new technology innovation, all of these things require money aside from the money to just keep the lights on. So all that money is funneled back into the system. So think about it this way, though. We're a nonprofit organization and anthem, which is a multi-billion dollar company, right?

00:27:41:05 - 00:27:54:10

Dr. Alan Adler

Many, many billions dollars owes us hundreds of millions of dollars. And this is a, you know, an our interest free loan, basically that they're just have and no interest in paying it back.

00:27:54:12 - 00:27:57:08

Leslie Schlachter

I mean, what's the likelihood where you're actually going to see that money.

00:27:57:10 - 00:28:02:09

Dr. Alan Adler

So we will take them to arbitration. And we are working on getting, you know, that money back.

00:28:02:10 - 00:28:33:07

Leslie Schlachter

We're going to take you to arbitration. I'm talking to anthem. So here we are a health system caring for patients, doing research to care for future patients, reinvesting our money for innovation, research, clinical care. Just the circle of money keeps cycling around for the patient, for the patient, for the patient. An anthem is essentially stealing money from us.

00:28:33:09 - 00:28:37:00

Leslie Schlachter

And how much is there? How much does their leadership make per year?

00:28:37:03 - 00:28:50:19

Dr. Alan Adler

No idea, but millions of dollars. And I'm not even begrudging them that. But you know, their their company makes billions of dollars in profit. And you know, we're they were arguing with us over less than $20 million.

00:28:50:23 - 00:28:59:07

Leslie Schlachter

So you were saying that, like, you know, they make a lot the and you don't begrudge them.

00:28:59:07 - 00:29:20:16

Dr. Alan Adler

I don't begrudge them their. Hey, you know, I don't begrudge our leadership for making what they make. You know, there's a lot involved. Anthem makes billions of dollars in profit, and we just want them to consider the patients. Right. So if I could say one thing, you know, to the anthem leadership to Ella Vance, which is the mother company, come to the table, right.

00:29:20:16 - 00:29:43:13

Dr. Alan Adler

It's reasonable, you know, put your representatives, have them negotiate in good faith. Do it for the patients. Right. There are 225,000 patients that really want this to happen. There are 9000 providers. And if you don't want to do it for the patient, then do it for your clients, right? Those are the employees that are, you know, 80% of your business is self-insured.

00:29:43:16 - 00:29:58:00

Dr. Alan Adler

They're bearing the brunt of this. If they're going to different hospital systems, it's costing them more money. So now is the time. Please come to the table. We the deal. If we work around the clock, we can get this done in a matter of a week, if not even less.

00:29:58:05 - 00:29:58:16

Leslie Schlachter

Right.

00:29:58:16 - 00:30:10:18

Dr. Alan Adler

And we were close to a deal before they reneged. So if these are not the proper people that need to negotiate on your behalf, then get the proper people there. Our team is ready, willing and able.

00:30:10:20 - 00:30:22:18

Leslie Schlachter

I can imagine that they're ultimately going to lose money on this deal because they're pissing off a lot of patients and organizations, and then ultimately they're going to switch insurance companies.

00:30:22:20 - 00:30:50:11

Dr. Alan Adler

So I mean, that's what patients can do, right? So if patients are unhappy with what's happening, they should call anthem and complain, they should get their HR department, their benefits, people involved. They should call anthem and complain. And you know, if they want to, they obviously can switch insurance companies. And if they're really having trouble, even with continuity of care, if it's an employer based deal, they can call the Department of Financial Services and file a complaint against anthem.

00:30:50:14 - 00:30:59:16

Dr. Alan Adler

If it's a government plan, they can call the Department of Health. And I don't think anthem wants to get on the bad side of either one of those organizations.

00:30:59:19 - 00:31:17:03

Leslie Schlachter

Yeah. One of the things that patients should know is, I know how frustrating it is to deal with insurance companies. I know how frustrating it can be to even to make a doctor's appointment. Everything related to your health is really stressful, especially if you're scared. If you have a diagnosis of something, you're scared. You're not sure what's going to happen with your medications and all of your appointments.

00:31:17:06 - 00:31:38:00

Leslie Schlachter

Just like take a deep breath, make the phone call asked to speak to HR. Complain. Ask for what you can do. If you don't get the answer you want, call back the next day. Like you just have to take a deep breath. Maybe have a glass of wine and just get through the moment because it's going to take thousands of people to do that, to actually move the needle in this situation 100%.

00:31:38:00 - 00:31:57:28

Dr. Alan Adler

And it's, you know, one patient calling it may not do it, but thousands of patients calling and especially the HR benefits people calling that. Yeah, that will get the attention of anthem and hopefully get them back to the table. We just want a fair deal. We just and we were we were there. So it's it's kind of mind boggling that we're still at this point.

00:31:58:02 - 00:32:20:07

Leslie Schlachter

Yeah. My heart is I have so many patients, not only my frustrated by the amount of work I have to do to deal with this right now. So I get I get my cell phone out to a lot of patients. So my cell phone, my chart, messages, emails. At this point I have an email signature about this. It's a lot of time and energy, and I'm just one provider that's going into explaining what people need to do, and then they get a different answer from anthem.

00:32:20:07 - 00:32:35:22

Leslie Schlachter

And I have to re explain, and I don't even have all the answers half the time. And we're losing patients and it's sad. I don't want to lose my patients. I don't want to have to worry about like the people I have scheduled for April that we're now. They've been waiting this whole time to have surgery, and they have to go start with someone new again.

00:32:35:22 - 00:32:36:21

Leslie Schlachter

That's awful.

00:32:36:24 - 00:32:57:01

Dr. Alan Adler

Oh, it's it's incomprehensible, honestly. And that they're doing this and it's, it's it's beyond sad and that's, that's who bears the brunt of it. It's it's the patients mostly. But you know, our providers want to see these patients. I mean some of our providers, if they could they would see them for nothing. Right? I mean that's that's how dedicated our providers are.

00:32:57:05 - 00:33:04:16

Leslie Schlachter

Yeah, I did yesterday. Yeah. Anything else that you want to add that we did not speak on? Did I miss anything super important?

00:33:04:18 - 00:33:19:22

Dr. Alan Adler

No, I think we covered it all. And, you know, I think my message to the anthem and Ella Vance leadership is is clear. We are here. Our team is ready. You know, we'll work around the clock to get this done. Just come to the table and negotiate in good faith, okay.

00:33:19:25 - 00:33:25:25

Leslie Schlachter

And then we're going to add in you're open to arbitration if that's what you need is for meeting a mediator to help you get there.

00:33:26:02 - 00:33:29:03

Dr. Alan Adler

If we can we can have one. That would be great okay.

00:33:29:05 - 00:33:29:19

Leslie Schlachter

Thank you so much.

00:33:29:19 - 00:33:30:18

Dr. Alan Adler

My pleasure.

00:33:30:23 - 00:33:52:00

Leslie Schlachter

That's all for this episode of The Vitals. And that was a lot. I'm your host, Leslie Schachter. Subscribe to the vitals and the Mount Sinai Health System's other video podcast programing on YouTube, Apple Podcasts, Spotify, or wherever you get your podcasts. To get in touch with the show or to suggest an idea for a future show or episode, you can email us at podcasts at Mount sinai.org.