Attorney General Says Provider Agreements In Effect

Wyoming Medical Society (WMS) has spent the last two weeks working on coordination with the State Insurance Commissioner and the receivership partners at WINhealth asking those groups for assurances on continued payment as well as questions on the validity of provider agreements. Here is what we know as of Nov. 2.

Providers receiving assurances for payment
Last month WINhealth announced that it would not take part in the individual market for the 2016 year, signaling its intention remove nearly 60 percent of its clients from its membership.

Things would only get worse this month as the Wyoming State Insurance Commissioner assumed control of WINhealth about three weeks ago due to financial concerns. The company was placed into receivership and Joe Holloway from Regulatory Services Group (RSG) is effectively running the day-to-day operations of WINhealth. Holloway said he was interviewing staffers at WINhealth and trying to retain those in important positions through bonuses.

Claims payments are continuing and will through the end of the year. Insurance Commissioner Tom Glaus said last week that he has approved $3 million in payments over the last three weeks. Glaus said he believes WINhealth cash will hold out through the end of the year, but adds it will be “touch-and-go.”

After the first of the year it is likely that the insurance commissioner will ask the court to move WINhealth into liquidation. Once that happens, two important things take place. For patients, all WINhealth plans will be void within 30 days. For providers and others that WINhealth owes money to, the Wyoming Life and Health Guaranty can kick in.

The Wyoming Life and Health Guaranty is a sort of non-profit reinsurance program that is available to pay WINhealth debts. Glause said there might be as much as $33 million available to pay claims and other WINhealth debts, however that cash is largely unavailable until the liquidation process kicks in.

Glaus and Holloway have repeatedly told WMS that providers will be paid for their work and Glaus plans to send out a letter directly to the state’s providers outlining the case for why he believes that is the case soon.

Provider agreements
As WMS members know, the provider agreement is the bedrock of the third party payer-provider relationship, governing when, how and what providers will be reimbursed for services. Several WMS members have sought clarification from WMS regarding the continued validity of their WinHealth provider agreements (which reference termination if WinHealth breaches the agreement), and questioning whether those agreements remain in effect with WinHealth’s receivership. After reviewing the provider agreement, and the Insurance Commissioner’s receivership Petition, the WMS’ legal counsel, Nick Healey, has sought clarification from the Insurance Commissioner and the Wyoming Attorney General on whether they believe WinHealth’s provider agreements remain in effect. Today, the attorney general’s office offered its opinion, saying it believed the agreements are still in effect.

“Our position is that the agreements remain valid and in-force,” wrote Jonathan Coppom of the Attorney General’s office. “As a result, we advise providers to continue as they did prior to the commencement of the Winhealth rehabilitation–continue to see patients, existing and new, under the contract, and bill under the contract just like they did in the past.”

Healey, has asked the Attorney General to provide the reasoning for its position, which appears to run counter to the agreement’s language it is simply void if WINhealth fails to conform to Wyoming’s HMO statutes. Healey expressed concern that WinHealth’s provider agreements appear to be simply void, since the Insurance Commissioner’s receivership Petition states (twice) that WINhealth failed to maintain the “surplus,” required under Wyoming law (starting in the summer of 2015). As of the time of this release, the Attorney General’s office has not provided further comment.

Healey said that, while he recommends WMS‘ members consult their own legal counsel regarding their obligations under the WinHealth provider agreement, WMS’ significant concerns on the validity of the provider agreements remain, notwithstanding the AG’s stated position. Healey stated that Wyoming physicians face a difficult choice – assume the agreements remain valid, see WinHealth patients and seek reimbursement as usual, or treat the provider agreements as void and act as “out of network” providers, requiring WINhealth patients to make payment up front and seek reimbursement on their own from the company. While there appears to be little risk in treating the provider agreements as intact at this point, Wyoming physicians could end up on the short end of the stick if WINhealth runs out of money to fund all reimbursement claims.  Therefore, Healey advised, WMS members should exercise due caution in deciding how to proceed.

What is happening to patients with WINhealth?
WINhealth’s decision not to be a part of the individual market means those with WINhealth policies purchased on the individual market will need to purchase new policies with Blue Cross Blue Shield this month as open enrollment takes place. Their insurance through WINhealth is still in effect until the end of the year.

Those who have purchased insurance through small groups, through employer health plans, will have their policies in effect until the anniversary date of the policy. However, Holloway said last week the insurance company is trying to get those policies to be picked up by other carriers. He said WINhealth had no intention of letting those policies come to term. The thinking is that would slow down the liquidation process as all WINhealth policies will be be void 30 days after WINhealth goes into liquidation.