ETMC Files $1 Million Suit – Wants To Be Included In PPO



The hospital says exclusion from the preferred provider networks (PPO) of these companies has created “serious and negative consumer impact.”

Note: Another good reason to leave the managed care world and pay medical caregivers a transparent, fair and reasonable reimbursement based off pre-determined benchmarkes.

ETMC files $1 million suit against three major health insurance carriers

Posted: Jun 02, 2015 2:19 PM CDTUpdated: Jun 02, 2015 2:42 PM CDT

(KLTV) –

East Texas Medical Center Tyler has filed a $1 million lawsuit against three of the largest health insurance carriers in East Texas.

The hospital says exclusion from the preferred provider networks (PPO) of these companies has created “serious and negative consumer impact.”

According to the suit, Blue Cross & Shield of Texas, Aetna Health Inc., Aetna Life Insurance Company, Cigna Healthcare of Texas, Inc. and Cigna Health and Life Insurance Company were all named as defendants.

ETMC Tyler, one of the largest hospitals in the region, alleges that the exclusion lessens consumers’ choice of quality health care providers and increases healthcare costs for some patients. The suit also states that the exclusion of ETMC Tyler is contrary to the provisions of the Texas Insurance Code, which requires “a fair, reasonable, and equivalent opportunity to apply to be and to be designated as a preferred provider.”

The code states further that carriers “may not unreasonably withhold a designation as a preferred provider.”

“We are a charitable not-for-profit hospital seeking to fulfill our mission of providing for the health care needs of the residents of East Texas,” said Elmer G. Ellis, president and CEO of the East Texas Medical Center Regional Healthcare System. “Litigation was the last resort but sadly it is necessary if we are to fulfill this important mission.”

The suit notes that ETMC offers East Texas the only renal transplant and deep brain stimulation services and the only Level 1 trauma center. ETMC is one of only two hospitals in Smith County that provides inpatient psychiatric services and is the only hospital in East Texas that provides inpatient psychiatric services for children and adolescents. Patients needing these services must leave the area or face higher deductibles and/or copays if they seek care at ETMC’s flagship hospital in Tyler.

A similar lawsuit was filed in November 2014 by Texas Spine & Joint Hospital in Tyler against Blue Cross Blue Shield. The hospital said it was seeking damages for what it called years of disputed payments for patient care provided to BCBS members. The hospital also argued that BCBS is in violation of the Texas Free Enterprise and Antitrust Act by having only one contracted or “in-network” hospital facility in the Tyler area.

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