Several Blue Cross Blue Shield of Oklahoma members say they're in jeopardy of not receiving life-saving treatment
OKLAHOMA CITY (KFOR) - A metro-based eating disorder treatment facility claims they were cut from Blue Cross Blue Shield of Oklahoma's in-network provider list three years ago, leaving several BCBS members wondering how they'll be able to afford treatment.
Merrilee Ishii told KFOR she has had an eating disorder for 20+ years.
She is a BCBS member who has been receiving treatment from Living Hope since 2018.
Ishii has requested several service/procedure approvals from BCBS in which each one has been approved.
In BCBS authorization letters, it reads approval through the BCBS Health Care Management Department is not a guarantee of payment of benefits.
However, Ishii said she was promised BCBS would foot their portion of the bill.
Ishii provided News 4 with a document showing BCBS was supposed to pay $137,630.
As of Tuesday morning though, Ishii claims BCBS hasn't paid a cent.
Instead, she has had to fork over $68,215 in medical bills in the last five years.
"I'm a mom of three and that's a lot of things that they're not getting or, you know, money we're not saving for them or trips or, you know, I'm a musician. That's guitars I'm not getting or, you know, recording time in the recording studio. It affects a lot of, you know, an eating disorder affects so many aspects of your life," said Ishii.
Ishii said to pay that bill meant having to borrow money from family members and taking out loans.
"This is something that [BCBS] is supposed to be able to have help for. This is a health issue. It's not just it's not extraneous. It's something that is absolutely medically necessary," stated Ishii.
Ishii received a letter in May 2020 letting her know her treatment would no longer be covered.
She immediately thought, "How am I going to keep doing this?"
Ishii then thought to herself she or her health didn't matter in the eyes of BCBS.
The Owner of Living Hope, Dr. Meghan Scears said she was shocked to see she was no longer in-network with BCBS because she hadn't received any notice about it.
"I've had many forms of communication with higher level administrative staff at both Blue Cross Blue Shield of Oklahoma, as well as with higher level administrative staff with their parent company, HCC. I have asked for meetings and have not been granted that. We have been in discussion to try to understand why it is that our attempts for contracting are being denied and why it is that we have been unable to reach a contract agreement," explained Dr. Scears.
Dr. Scears said she did have a phone conversation with the BCBS Oklahoma Director of Provider Network Operations.
She did record that conversation and played it back for News 4 Tuesday morning.
"We look to see if the type of services being performed is a network need and if it's a benefit and if it is not a benefit to our members, then it is not a network need for us," Dr. Scears quoted BCBS in their phone conversation.
According to NBC, the National Eating Disorder Association reports a more than 53 percent increase in call volume to its helpline since the start of the pandemic. Just over a third of those patients are ages 13 to 17, and about 36 percent are 18 to 24 years old.
Dr. Scears said she received 50-60/month from BCBS members who are looking to receive treatment from Living Hope, so she doesn't understand how there's not a demand in-network for her services.
"We have a lot of patients that come here for help that do hold that insurance. And we also have a lot of patients who call us needing help, pretty desperate because they're very sick and they're unable to come at this time because we are out of network unless they want to cash pay, which is obviously difficult and not something that we want for them," added Dr. Scears.
Dr. Scears said BCBS also told her the number of calls she's receiving from BCBS members "doesn't matter."
Dr. Scears said she has since emailed BCBS to continue the conversation.
That email was allegedly sent in January and she has not heard from anyone since then.
BCBS was not available for an in-person interview, but did send News 4 a statement.
"Our members are our priority. We are committed to providing them access to quality, cost-effective physical and behavioral healthcare, in accordance with their specific benefits. In addition to the in-network individual health care professionals who treat behavioral health, our provider network includes Oklahoma Children’s Hospital OU Health in Oklahoma City and Laureate Psychiatric Clinic and Hospital, part of Saint Francis Health System,in Tulsa. Both Oklahoma Children’s Hospital OU Health and Laureate offer nationally recognized eating disorders programs. We are confident in our network of providers and are always ready and willing to help members find the most appropriate in-network doctors or health care professionals for their specific needs."
Blue Cross Blue Shield Oklahoma
BCBS also stated Living Hope has never been a facility in-network.
"Our statement that Living Hope Eating Disorder Treatment Center has never been in-network is accurate. Dr. Meghan Scears was formerly in-network as a family physician until May 2020. We are continuing to look into this inquiry," explained BCBS.
Dr. Scears told KFOR that statement is false.
"I’m very shocked and have no idea what game they are trying to play. We have thousands of claims from patients who were in our IOP and/or PHP program from 2012-2020 when they cut the contract that were processed as in-network, as well as for outpatient treatment," said Dr. Scears.
She also explained although OU Health and Laureate Psychiatric Clinic and Hospital are in-network for BCBS members, the two are lacking the treatment resources Living Hope offers.
"Living Hope Eating Disorder Treatment Center provides unique services in the state of Oklahoma, including being the only eating disorder treatment center in the state that has intensive outpatient program for patients, as well as the only center in the state that takes care of male patients and patients that are members of the LGBTQ population as well as medically complex patients," said Dr. Scears.
Dr. Scears said taking legal action against BCBS is on the table.
Ishii said she, along with several other BCBS members have spoken with lawyers about taking their next steps in possibly filing a lawsuit against BCBS as well.
"I would like in the end for Blue Cross Blue Shield to pay for people to get treatment and for those who have been trying to get treatment, for them to be able to get that treatment," said Ishii.
For now, Ishii said she is only receiving treatment once every three months because that's all she can afford at the moment.
Ishii plans to continue treatment at Living Hope.
"Our members with PPO plan coverage have out-of-network benefits, which pay in part for care from an out-of-network provider. If a member chooses to seek care from an out-of-network provider or facility, the member will pay more out-of-pocket for any care received by this provider or facility. We encourage members to call the number on their member ID card with questions about their coverage," stated BCBS.