Mount Sinai Health System Faces Contract Dispute with Anthem

Approximately 90,000 New Yorkers, including over 20,000 individuals on Long Island enrolled in Anthem insurance plans, will find their coverage with the Mount Sinai Health System jeopardized starting Sunday, unless an agreement is reached by the March 1 deadline.

The contract between Anthem and Mount Sinai lapsed on January 1, which resulted in patients losing access to over 9,000 Mount Sinai physicians under their insurance. Unless an agreement is finalized by Sunday, Anthem inpatients will face restricted access to Mount Sinai hospitals.

Brent Estes, who serves as Mount Sinai’s chief negotiator and senior vice president, mentioned that the contract contains a 90-day continuing care provision. This allows certain patients, especially those dealing with more intricate health issues like cancer, to still consult doctors.

However, for most patients, this 90-day window comes to an end on March 31, according to both Mount Sinai and Anthem. If a deal is not reached by that time, patients will have to either seek an in-network doctor or pay out of pocket.

“As of Sunday, we are preparing for a network outage,” Estes told Newsday, referring to the hospital. “Our doctors have been out of network since January 1, and we’ve been working on this for a while. We hope to finalize something soon.”

This ongoing contract dispute might mean that some Long Island Anthem policyholders could face much higher bills for visits to Mount Sinai doctors starting January 1. Such visits would then be categorized as out-of-network care. There are 17 Mount Sinai clinics located on Long Island.

From Sunday, treatments and hospital stays at Mount Sinai facilities, including Mount Sinai South Nassau in Oceanside, will also be deemed out-of-network for Anthem patients unless an agreement is made.

“If we don’t come to terms by March 1, individuals on Anthem and other Blue Cross Blue Shield plans will be shifted to a smaller and more expensive network with lower quality care,” Mount Sinai stated on its website.

Key topics under negotiation include resolving outstanding accounts and the $450 million unpaid bills that Mount Sinai claims it owes to Anthem.

Anthem representatives argue that Mount Sinai is requesting fee increases above inflation rates, while Mount Sinai contends that its demands align with or fall below the increases sought by other healthcare providers in the area.

“We’ve held productive discussions with Mount Sinai and are hopeful for an agreement that maintains affordable access to both physicians and hospitals for our patients and their employers,” Anthem commented in a statement.

According to the state attorney general and Anthem, patients currently dealing with serious health conditions or those needing pre-scheduled surgeries, as well as pregnant women, can continue receiving treatment at in-network rates for 90 days post-contract expiration. Additionally, postpartum care may extend beyond that period for women.

Gisele Andrade, a 17-year-old from Port Jefferson, is one of the patients affected by this situation. She underwent a rare intestinal transplant a decade ago and has faced numerous health challenges since, including a brain tumor related to post-transplant lymphoma.

After taking six years off from school, Andrade has returned and is currently a 10th grader. Sadly, she has developed kidney issues recently as well.

Her family emphasizes the importance of having access to a specialized medical team for her ongoing treatment. “It’s a bit intimidating. She really needs a doctor,” her mother, Tonica Andrade, expressed. “Honestly, I believe they should work it out. Finding fairness is what matters for everyone involved.”