Far more Florida Keys residents than just Monroe County employees appear to be affected by Fishermen’s and Mariners hospitals having a new physician group operating their emergency rooms who do not accept multiple popular and common healthcare plans.

County employees learned less than two weeks ago that Florida Blue (Blue Cross Blue Shield) insurance was not being accepted by the new physician’s group, SHI Keys, LLC, which manages both hospitals’ ER departments.

Blue Cross, however, isn’t the only health insurance plan that SHI Keys does not accept. According to SHI president Dr. Ruddy Valdes, Aetna, United and Cigna health insurance plans are also not accepted at this time, although both Fishermen’s and Mariners hospitals accept those plans for hospital services.

This means far more Monroe County residents are adversely impacted by this situation. County Employee Services Director Bryan Cook estimated last week that there are upward of 2,300 Monroe County employees, family members and retirees covered by the Florida Blue plan, which also includes employees and families of businesses and municipalities outside the Monroe County umbrella, such as the Florida Keys Aqueduct Authority, Keys Energy Services, the City of Marathon, Village of Islamorada and other county subsets.

“We are currently out-of-network for Aetna, Cigna and United Healthcare, but we are working diligently to become in-network providers for the insurance plans that are contracted with Mariners Hospital and Fishermen’s Community Hospital,” Valdez said Thursday. “We expect to resolve these matters shortly.

“In the meantime, SHI Keys is committed to ensuring that emergency patients at Mariners Hospital and Fishermen’s Community Hospitals can promptly obtain an explanation and resolution to billing questions, and that no patient incurs additional cost because of this current out-of-network status.”

But now, with at least three additional healthcare plans not currently accepted by the ER physician’s group, potentially thousands more Monroe residents who carry those plans fall into this coverage ‘gap.’

Cook has been working aggressively to resolve this with both Baptist Health South Florida and SHI Keys. He said in a follow-up call this week that some progress is being made but acknowledges it is a slow process. Adding the other major healthcare plan participants has expanded his efforts.

“I’m trying to solve this on two fronts, for both county employees as well as all county residents who are affected,” Cook said. “I manage the health plan for the county and have examined the cases where 55 county employees since Jan. 1 have had problems with coverage. In each of those cases, balanced billing has been the solution and all these cases are in the process of being resolved.”

Balanced billing is where providers bill a patient for the difference between the amount they charge, and the amount the patient’s insurance pays. The amount that insurers pay providers is almost always less than the providers’ “retail price.” Some providers, as in this case SHI Keys bill the patient for the difference, or balance, which is called balance billing. Providers in-network, like the two hospitals, accept insurance payments as payment in full, less any applicable co-pays, deductible or co-insurance.

Cook said the five Monroe County commissioners, as well as County Administrator Roman Gastesi, understand it’s in the county’s interests for him to address this on both fronts, as he is advocating for both county employees and county residents.

The SHI contract has been in place less than a year, and Cook confirmed when the contract was signed, “It would have been better if BHSF would have looked at the local market and the customer base and required a stipulation to the physician’s group to accept the insurances in this market.”

Cook confirmed these four healthcare plans are the most widely used in the county. But he added, “I don’t know how many people there are who work in the Monroe County School District, the FKAA and all these other affected employers who will have these same problems”.

He said there is nothing in writing from SHI currently that outlines what they’ll do or pay. But he did say that while this will take time to resolve, “all the right people are at the table doing the right things.”

BHSF contracted with SHI Keys earlier this year for ER services after records show the group was formed in November 2020. They operate with one or more individual providers who practice different areas of specialization.

In a statement about the situation, Valdes said, in part:

“SHI Keys is proud to care for the Keys community and are working diligently to become in-network providers for the insurance plans that serve Monroe County and that already have contracts with Mariners Hospital and Fishermen’s Community Hospital. We apologize for any inconvenience or confusion that this may have caused. Please rest assured that we are working to resolve this matter quickly, and we fully anticipate that we will become an in-network provider of these plans soon. Patients who have questions should call us directly at 386-516-5582.”

Company searches show a phone number and mailing address for SHI Keys in Ormond Beach, in Volusia County on Florida’s east coast, although a representative at that number said it was merely a billing company for physicians groups around the country. Another search referenced their address and phone number at Fishermen’s Hospital. A supervisor contacted at the Fishermen’s ER had no knowledge about SHI Keys.

Currently, county residents are urged to clarify their coverages before ER visits and treatment, which could be an afterthought for some patients and family members who are dealing with severe or life-threatening circumstances.

Several county officials have expressed deepening frustration surrounding this situation, given the special tax Middle Keys residents are paying to fund the rebuilding of Fishermen’s. According to Monroe County, $2.25 million has been paid to Baptist Health from the Middle Keys Health Care taxing district since its inception. The Marathon City Council votes every year to continue or cut annual funding, with the next vote in February 2022.

The Monroe County Commission has placed the issue on the Oct. 20 meeting agenda and has invited a Baptist Health spokesperson to attend and hopefully address the county commissioners as to resolution of the situation.

Monroe County Sheriff Rick Ramsay shared a situation one of his employees experienced recently. That employee visited the Fisherman’s ER with a severe appendix problem and is now deeply concerned about the potential high out-of-pocket billing from the attending physicians in the ER. Ramsay feels that with housing costs already high in the county, adding significant health insurance co-pays and out-of-pocket expense to the population makes the Keys an even more challenging place to work and live.

Cook was advised that BHSF is asking Monroe County residents who have questions regarding this issue, including the cost of an upcoming procedure, to contact Baptist’s Central Pricing Office at 786-662-7181. However, a call to this number didn’t reveal a clear understanding of the relationship between BHSF and the physician’s group.

Neither Jay Hershoff, local attorney and Board of Trustee member of Baptist Health South Florida, nor Fishermen’s and Mariners CEO Drew Grossman returned calls for comment.