Vanderbilt University Medical Center, a massive health care system in Middle Tennessee, will stay “in network” with the state’s largest insurer, Blue Cross Blue Shield of Tennessee.

Vanderbilt’s 180 locations — which include clinics, hospitals and rehabilitation centers — provide about 3.2 million patient visits annually. Blue Cross Blue Shield covers about 3.5 million Tennesseans — roughly half the state’s population.

“We know our members value Vanderbilt’s services, and we’re glad to maintain their access to high-quality, affordable care,” reads a media statement attributed to Scott Pierce, BlueCross’ executive vice president and chief operating officer. “Stability is also important to our members’ peace of mind, and strong provider relationships like ours meet that need.”

Over the past several years, tensions between providers and insurers have made agreements like this harder to come by.

Here’s how these deals tends to work: health providers like hospitals say how much they want to charge for their services, insurers say how much they’re willing to pay, and the two sides work to meet in the middle.

If the two companies work it out, the insurance company’s clients get to keep going to that provider at a discounted, “in network” price. If the companies don’t work it out, the provider is considered “out of network,” and it becomes so expensive for the patients that they usually have to find care somewhere else.

This recently happened with Blue Cross Blue Shield in Chattanooga. CHI Memorial hospital lost its in-network status. That hospital’s parent company, Chicago-based CommonSpirit, has criticized insurance companies like Blue Cross Blue Shield. They say it’s getting more expensive to provide health care, but insurers aren’t wanting to raise their rates enough to share the burden.

Blue Cross Blue Shield of Tennessee is the insurer for City of Memphis employees. It was in contentious negotiations with Methodist Health Care back in 2022. The Commercial-Appeal reported 14,000 patients could have been affected. The two ended the dispute in June of 2023.

But these contentious negotiations aren’t unique to Blue Cross Blue Shield.

Last summer, tensions were simmering between Cigna and HCA Healthcare. The two sides were more public about how difficult negotiations were going. Their communications highlighted the conflict inherent in these fights: providers say they need higher payments for their services as costs go up, but insurers say increasing the rates would just make premiums more expensive for patients.

“We want to keep health care affordable for our clients and customers, especially as they are managing rising prices due to inflation,” a Cigna representative wrote in a statement last summer. “Unfortunately, TriStar Health (HCA) is demanding significant rate increases that are substantially more expensive than other health care providers and will increase what people in Tennessee pay for their health care needs.”

Through an FAQ, HCA’s website shed some light on its position.

“We want to continue our relationship with Cigna Healthcare,” one answer read at the time. “But it is critical that we are able to agree upon a reasonable contract that allows us to maintain access to quality care that our patients, physicians, leadership and staff have come to expect.”

The impasse was especially concerning in Nashville, where thousands of Metro employees are enrolled in Cigna coverage.

The mayor at the time, John Cooper, released statements urging an agreement.

“This dispute between HCA and Cigna, if not resolved quickly, will impact tens of thousands of city employees, city retirees, teachers and others who work in government throughout Tennessee,” it read.

They did eventually work it out.