Orthopedic Surgeons Return To Premera Insurer Resolves Dispute With Clinics Over Rates

Four Spokane orthopedic clinics have returned to the Premera Blue Cross provider network, restoring patients’ access to the majority of orthopedic surgeons in the area.

The four clinics dropped out of Premera more than a year ago, frustrated by low reimbursement rates. Premera is the state’s second-largest health insurer with about 950,000 subscribers.

Dr. Alex Verhoogen, a private-practice orthopedic surgeon in Spokane who dropped out of the network, also has returned.

With the return of the surgeons, the network’s supply of orthopedic surgeons is about three-fourths of what it was before the exodus.

Last year, 33 of 41 Eastern Washington orthopedic surgeons terminated contracts with the majority of Premera’s health plans in a dispute over fees. As of this month, 23 of the surgeons are back with Premera.

“It’s such good news for patients who have been caught in the middle of this,” said Leanne Mason, administrator of Northwest Orthopaedic & Fracture Clinic, which has 13 surgeons at four Spokane offices. “Like any negotiation, there was a compromise from both parties that made it work.”

Premera’s orthopedic patients experienced longer-than-usual waits during the past year for appointments and surgery with the few surgeons who remained in the network, Mason said. Some patients paid higher out-of-pocket costs by seeing non-participating surgeons, she added.

Orthopedics is the medical specialty devoted to the diagnosis and treatment of injuries and diseases of the body’s musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles and nerves.

Surgeons had complained they were caught between low reimbursements and higher costs, pushing them to refuse to accept Premera payments.

Over the past 14 months, Premera raised its reimbursement rates by nearly 12 percent, said Curtis Taylor, Premera’s senior vice president and general manager.

“Fourteen months ago it was a hassle to work with health care companies, and our goal was to change the way we do business with physicians and make it easier,” Taylor said.

Beyond the better reimbursement rates, Taylor said the company also has improved its referral and eligibility process.

“We rebuilt trust and relationships,” he said. “It’s something we are celebrating and something orthopedic surgeons and patients are celebrating as well.”

Taylor said he expects there is a 50/50 chance that the remaining 10 surgeons who dropped out will come back to Premera within the next three months.

In addition to Northwest Orthopaedic & Fracture Clinic, the other clinics that have rejoined Premera include Inland Orthopaedics of Spokane, Orthopaedic Specialty Clinic of Spokane, and Spokane Orthopaedic & Fracture Clinic.

The agreements cover the following health plans: MSC/Premera Blue Cross traditional and preferred plans; Premera Blue Cross participating and preferred plans; Premera Blue Cross Blue Choices; Premera Blue Cross individual managed care; and Premera HealthPlus.

All 41 orthopedic surgeons remained contracted under three of Premera’s managed care plans. They are MSC Care, PrimeCare and Classic Care health plans.

Overall, about 20 percent of Premera’s subscribers have managed care plans.