August 27, 2008

Center’s Patients Unclear on Care

By Monica Rodriguez

POMONA - More than a week after Pomona Valley Hospital Medical Center ended its contract with Anthem Blue Cross, the insurance company's members are still calling the hospital's help line with questions about receiving care.

And the insurance company members aren't the only people with questions. Doctors also have questions, said hospital spokeswoman Kathy Roche.

Among those who attended a recent physicians' meeting was Dr. Sri Gorty, a radiation oncologist with the hospital's Robert and Beverly Lewis Family Cancer Care Center.

"Going in, I was a little bit scared," he said this week.

Gorty, who has admitting privileges exclusively at the hospital, was concerned patients who are Anthem Blue Cross members wouldn't be able to access services there. After the meeting, Gorty felt better.

Based on the various rules, the vast majority of his patients will be able to see him and receive care at the hospital, he said.

Overall, most Anthem Blue Cross members will still be able to get the services they need at the hospital until mid-December, even after the break between the hospital and the insurance company, said Roche.

More than a dozen exceptions exist that would allow patients to receive care at the hospital or through its doctors, Roche said Monday, under a plan developed by the insurance company that received approval, with some conditions, of the state Department of Managed Health Care.

Anthem Blue Cross gave doctors who have admitting privileges only at Pomona Valley 120 days from Aug. 15 to secure privileges at other hospitals that do have contracts with the health insurance company. In the meantime, their patients will be covered at PVHMC.

Sixty-five percent of all the 2007 Blue Cross admissions to Pomona Valley involved doctors who had privileges exclusively at the hospital, Roche said.

The 120 days is the period officials with the state agency said is sufficient time for doctors to secure privileges elsewhere, said Lynne Randolph, state spokeswoman.

So far patients haven't come to Gorty with questions, but he's prepared for them if they do, he said.

"I'd reassure them that they're not going to be affected," he said, adding that he'll make sure they get the hospital's help-line number in which they can get answers to their questions.

Dr. Duane Styles, a physician with the hospital's Family Health Center, came away from the physicians meeting with answers that, yes, X-rays and scans will be covered by the insurance company.

Many people have questions, even away from the hospital.

"I spent the weekend talking with friends because they were very confused," he said.

Styles' friends have Anthem Blue Cross, and when it comes to seeing a doctor "they want to have a relationship with me," Styles said.

Styles, who has more than 30 years in the medical field, said he expects the contract matter between Anthem Blue Cross and the hospital to be resolved and hopes it will happen within 120 days.

"I really have to believe this will be resolved," said Styles, who is not the only physician at the Family Health Center to have admitting privileges only at PVHMC, he said.

If the matter isn't resolved after the 120 days and patients want to continue to see Styles, they'll have to switch to a different insurance company, he said.

The hospital's help line is available for questions, she said.

Between Aug. 15 and 9 a.m. Tuesday, the help line received 243 calls, with the number spiking up at various times, Roche said.

"We want people to have accurate information," she said.

Hospital exceptions

Although the contract between Pomona Valley Hospital Medical Center and Anthem Blue Cross was terminated Aug. 15, there are several exceptions that make it possible for a large number of people to receive coverage for care or services through the hospital or its doctors.

The following is a list of some exceptions; there may be others:

A patient may receive care at PVHMC if his primary care doctor or his referred specialist is unable to admit him to an alternate hospital. Services will be covered by the insurance company for 120 days from Aug. 15.

Patients in an active course of treatment for an acute medical condition.

Patients in an active course of treatment for a serious chronic condition such as diabetes, heart disease or cancer.

Pregnant women regardless of trimester and women in the immediate post-partum period.

Patients in treatment for a terminal illness.

Children under 3.

Patients scheduled for surgery or other procedures within 180 days of Aug. 15.

In an emergency, people who require emergency- room services can access them at PVHMC with costs handled as in-network benefits.

A patient can receive services at PVHMC if the alternate hospital where his doctor has admitting privileges doesn't provide the necessary services or they aren't available

The patient is enrolled in the HMO program with Anthem Blue Cross HMO and has authorization from his medical group to go to PVHMC.

The patient is enrolled in the PPO program of Anthem Blue Cross and has out-of-network benefits.

Questions regarding these exceptions or other circumstances can be addressed by calling the hospital's help line, (909) 865-9664. The line is staffed from 6 a.m. to 9 p.m. Messages may be left, and a staff member will return the call.

Patients who are in ongoing treatment programs for conditions such as cancer, who are scheduled for surgery or are expectant mothers must inform Anthem Blue Cross they qualify for continuity- of-care service.

Should they have trouble working with the insurance company, Anthem Blue Cross members can contact the state Department of Managed Care at or by calling (888) HMO-2219.

The Anthem Blue Cross Transition Assistance Department number is (888) 486-4227.

Source: Pomona Valley Hospital Medical Center

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