The rift between Adventist and Blue Shield could hit patients in California

Emergency room physician Sarah Dunn examines a patient at Adventist Health Hospital in Sonora on March 28, 2022. Thousands of Californians face higher medical costs after contract negotiations between Adventist and insurer Blue Shield of California broke down.

Max Whittaker/Special to The Chronicle

Thousands of Californians may have to pay out-of-network medical costs to get to the nearest hospital after contract negotiations between Adventist Health and Blue Shield of California — the state’s main health care provider and health insurer — broke down last week .

Adventist Health and Blue Shield had been negotiating a new contract for about 11 months, but were unable to reach an agreement on reimbursement rates before the previous contract expired on Dec. 1. That means people who had Blue Shield plans could be included in having to pay higher out-of-network rates for hospital services like lab tests and imaging, or having to travel long distances to seek care in a network hospital.

The development affects all 17 Adventist hospitals in California, including Adventist Health St. Helena and Adventist Health Mendocino Coast. Applies to people with Blue Shield, Medicare Advantage and Medi-Cal managed care plans.

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This does not affect services at most Adventist outpatient clinics. These services are covered by a separate contract that expires in March or April 2024.

Blue Shield will continue to cover urgent care, the insurer said.

Adventist also contracts with insurers Anthem and Aetna and says patients who wish to continue receiving covered hospital services in the affected locations can contact those plans.

It’s unclear how many people are affected by the coverage cut. But in Tuolumne County alone, more than 6,000 Blue Shield members are no longer insured for hospital services at Adventist Health Sonora, an Adventist spokeswoman told the Union-Democrat.

In some rural parts of the state, including Mendocino County, Adventist is the only hospital or the closest one for miles, making the situation especially worrisome for Blue Shield patients who may have to drive farther for in-network care or incur higher costs to pay for care at Adventist, which is now considered out-of-network.

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Contract negotiations are common between health care providers and insurers, and disputes over reimbursement rates often arise. In these cases, both parties sometimes agree to extend the contract by a few months to give themselves more time to negotiate without disrupting patient coverage.

Nurses walk through Adventist Health Ukiah Valley Hospital on August 25, 2021. Thousands of Californians face higher medical costs after contract negotiations between Adventist and insurer Blue Shield of California broke down.

Nurses walk through Adventist Health Ukiah Valley Hospital on Aug. 25, 2021. Thousands of Californians face higher medical costs after contract negotiations between Adventist and insurer Blue Shield of California broke down.

Dean Fitzmaurice/Special to the Chronicle

Both Adventist and Blue Shield said they were disappointed they couldn’t agree on terms for a new contract and that they were ready to keep talking.

“We are deeply disappointed that we cannot reach a settlement with Blue Shield,” Adventist said in a statement. “We remain open to discussions and will provide an update if the current situation changes.”

Adventists said that in emergencies, patients should go to the nearest hospital, regardless of their insurance or ability to pay.

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Adventist said some people may continue to receive hospital services at in-network rates by claiming “continuity of care” benefits from Blue Shield. This may be provided if the nearest hospital to the patient’s home is more than 30 miles away or if the patient’s in-network provider cannot provide the service they need.

“It is our sincere hope that we can continue the dialogue with Adventist Health management and establish a new contract that provides members with high-quality care,” Blue Shield said in a statement. “We apologize for the inconvenience this is causing our customers and members.

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