As a Health Republic subscriber after state directs ‘hold’ on payments, is my care covered or not?

As a Health Republic subscriber, I was alarmed by the Newsday headline Friday morning: “NY State puts hold on processing Health Republic medical insurance claims”  See story.

What would that mean to me, my family and staff? We’re supposed to be covered through Nov. 30. In October, I paid the November premium for that coverage: more than $2,100.

It didn’t take long to get a scary glimpse into what might be unfolding. I had my annual physical scheduled for Nov. 18. My doctor’s office called Friday morning at about 9:40 to let me know that I was now considered uninsured, because they’d been notified that Health Republic would no longer be paying claims. Therefore, if I wanted to keep my appointment, I would be doing so as an uninsured patient and would be expected to pay out of pocket for services rendered.

Now, I certainly wouldn’t expect my doctor — or any health care provider – to donate his or her services because of my insurance company’s insolvency. Fortunately, my immediate need was not an emergency and, since I had already have new insurance lined up for Dec. 1, I suggested we just postpone my checkup till after that date.

But did new development mean I am now uninsured? What happens if I get sick and — God forbid — need to go into the hospital before Dec. 1? Or need surgery? Will I be headed for bankruptcy too, like the ill-fated health insurance co-op I signed up with? And what about people with ongoing critical care needs? The person insured by Health Republic who’s on chemo? Or what about a pregnant woman who’s going to give birth before the end of the month? What about the local hospital — and doctors who’ve already provided care or may be forced to continue to provide care? Are they going to get stuck with the tab? How could this be happening?

And — wait a minute! — what about the 2,100 bucks I paid Health Republic for health insurance for the month of November?

After spending nearly the entire day Friday trying to sort through this — as a reporter and as a subscriber — I’m sorry to say the only thing I’m sure of is I’m not getting a refund, no matter what.

A Health Republic’s customer service representative flatly denied — quite indignantly — that there was any kind of “hold” on payment of claims. “Then I wouldn’t be here answering this phone, would I?” She pooh-poohed the Newsday report as “something somebody read on the internet” (using the word internet as if it were pond scum.) I got much the same response from the guy who answered the phone at the Department of Financial Services consumer hotline. Nope. Ain’t happening.

Except it is.

The DFS’ own official spokesperson confirmed it for Newsday, though he didn’t answer my four phone calls or email on Friday. (I love government-employed press officers who won’t return reporters’ phone calls. I mean, that is, after all, their job. This is a phenomenon that’s become all too commonplace in the Cuomo administration, sadly. But that’s another column.)

And the spokesperson for the Healthcare Association of New York, which represents more than 500 hospitals, nursing homes and health care facilities statewide said the state issued the “hold” on Nov. 6.

PBMC’s president Andy Mitchell told me Friday hospital officials are trying to figure out what it all means for the hospital. One thing seems pretty clear: it’s going to take a significant financial hit.

It’s not clear if health care providers can legally pull out of the Health Republic network, now that they’ve been told they won’t — or may not? — get paid. Sure they have a contract with Health Republic. But if Health Republic is telling them they won’t get paid, what good is that contract? Not much. I recall a concept from my contracts class in my first year of law school. It’s called “anticipatory repudiation” or “anticipatory breach.” When notified of an anticipatory breach, the other party has a duty to “mitigate damages” — i.e. it can’t continue to provide services and expect more payment. Now, I’m not sure whether anything in any statute pertaining to health insurance co-ops or any provision of the Affordable Care Act changes this well-settled doctrine of contract law, but it seems to me the doctors have a case.

The scariest thing of all is how nobody really knows what the hell is going on or how this plays out.

The situation is “very very fluid,” says Andy Mitchell.

“It’s rapidly evolving,” said a press spokesperson for State Sen. Kemp Hannon, who chairs the state senates standing committee on insurance.

Our State Senator, Ken LaValle said it’s changing “almost by the minute.”

I spoke to LaValle twice on Friday. He suggested I make the call to the DFS hotline and see what they had to say. Obviously, they are not coming clean with consumers. He said the senate will be holding hearings to investigate the whole situation.

But that doesn’t help someone who needs health care, who has paid up their insurance premium and is now getting (there’s no nicer way to put this ) screwed — by the insurance company, under the supervision and with the blessing of our government.

“This is, quite honestly, a bowl of spaghetti that’s congealed and you just have to unwind it,” LaValle said.

Seems to me that’s an assessment that can be applied to a whole lot of government lawmaking nowadays. And inevitably, it’s the taxpayers and consumers who pay the price.

Denise Civiletti is an owner of East End Local Media Corp., publishers of RiverheadLOCAL. and SoutholdLOCAL. An award-winning reporter, including a “Writer of the Year” award from the N.Y. Press Association, she is an attorney and former Riverhead Town councilwoman (1988-1991). She lives in Riverhead with her husband and business partner, Peter Blasl. The views expressed in her column are hers alone.

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