JustCare

Tag: In-network care

  • If you’re in a Medicare Advantage plan, watch out! Your doctor or hospital might no longer be in-network

    If you’re in a Medicare Advantage plan, watch out! Your doctor or hospital might no longer be in-network

    Health care providers across the country look to be dropping their Medicare Advantage plan contracts like flies. Sometimes, physicians or hospital systems cancel contracts with Humana, UnitedHealthcare, Aetna, Cigna and other health insurers because they deny too many prior authorization requests, causing patient safety concerns. Sometimes, these health insurers fail to pay physicians and hospitals what they owe them. Whatever the reason, if you’re in a Medicare Advantage plan, watch out. Your doctors or hospital might no longer be in-network.

    Over the last few years, Medicare Advantage plans have been found to inappropriately delay and deny care. The Office of the Inspector General has twice now reported widespread and persistent inappropriate denials of care in some Medicare Advantage plans, with an average of 13 percent of claims wrongly denied. However, our government won’t tell us which Medicare Advantage plans are the bad actors.

    Data as basic as Medicare Advantage plan denial rates and disenrollment rates are not publicly available. Social Security Works has sent a Freedom of Information Act to the Centers for Medicare and Medicaid Services, requesting this information. But, so far, Social Security Works has not received a substantive response.

    Instead, we are seeing several large hospital systems and physician groups end their contracts with corporate health insurers offering Medicare Advantage. Most recently, MedPage Today reports that “two influential medical groups with San Diego-based Scripps Health are cancelling their Medicare Advantage contracts for 2024 because of low reimbursement and prior authorization hassles, leaving 30,000 enrolled seniors to look for new doctors, or different coverage.”

    The problem is not going away but rather looks to be getting worse. As Becker’s reports:

    • Mayo Clinic in Arizona and Florida no longer contracts with most Medicare Advantage plans.
    • Samaritan Health Services in Oregon terminated its contract with UnitedHealthcare.
    • Scripps is terminating Medicare Advantage contracts for its integrated medical groups in California.
    • Stillwater Medical Center, a 117-bed hospital in Oklahoma ended contracts will all its MA plans. It said that MA plans denied 22 percent of prior authorization requests; traditional Medicare denied 1 percent.
    • Brookings Health System, a 49-bed hospital in South Dakota ended its MA contracts effective 2024.
    • St. Charles Health System in Oregon is still on the fence but told its patients to enroll in Traditional Medicare.
    • Baptist Health Medical Group in Louisville, Kentucky ended its Medicare Advantage contract with Humana.
    • Adena Regional Medical Center is ending its Medicare Advantage contract with Anthem BCBS and managed Medicaid plans in Ohio, effective Nov. 2.
    • Regional Medical Center in Missouri ended its Medicare Advantage contract with Cigna and plans to drop Aetna and Humana in 2024.

    Here’s more from Just Care:

  • United Healthcare cuts costs and jeopardizes access to specialty care.

    United Healthcare cuts costs and jeopardizes access to specialty care.

    Corporate health insurers have many ways to cut costs, including only contracting with network providers willing to accept extremely low rates and restricting the number of specialists in their networks. In an opinion piece for the South Carolina paper, the Post and Courier, Eveline Wang MD, an endocrinologist, explains how UnitedHealthcare slashed her practice’s provider rates well below Medicare’s. In short, UnitedHealthcare forced Dr. Wang and her colleagues to end their network provider contracts, allowing UnitedHealthcare to cut costs while jeopardizing access to specialty care for enrollees relying on these providers.

    Because of its leverage, Medicare is able to negotiate low rates with physicians, hospitals and other health care providers. Medicare’s rates tend to be significantly lower than corporate health insurance rates. UnitedHealthcare proposed to pay endocrinologists in Dr. Wang’s practice rates that were well below Medicare’s and well below their cost of delivering care.

    Dr. Wang treats people with complicated diseases, including diabetes. There’s a shortage of endocrinologists in the US. People wait long stretches to see an endocrinologist. Cutting endocrinologist rates in Dr. Wang’s area significantly below Medicare’s rates and effectively forcing these providers to end network contracts could mean leaving  many of their patients to die.

    What was UnitedHealthcare thinking and how is it allowed to set provider rates that are inappropriately low? Physicians cannot be expected to accept a payment rate below their costs. For sure, UnitedHealthcare saves money by slashing provider rates and by pushing physicians who see patients with complex conditions out of network. But, to protect patients, these insurer tactics should not be allowed.

    Here’s more from Just Care:

  • UnitedHealth could force nearly 3,000 patients to forgo care or find new physicians

    UnitedHealth could force nearly 3,000 patients to forgo care or find new physicians

    Because the US Congress leaves it to corporate health insurers to negotiate health care provider rates and agreements, our health care costs are far higher than they should be. In addition, access to health care is often far more difficult than it should be. In Vermont, Valley News reports that UnitedHealth’s negotiations with doctors at the University of Vermont Medical Center might fail and UnitedHealth would then cut ties with physicians for nearly 3,000 patients, forcing them to forgo care or find new physicians.

    Corporate health insurers are legally obligated to think first and foremost about their own profits. The effects of their administrative, financial and other activities on patient care do not seem top of mind. So, it’s no surprise that UnitedHealth’s failure to reach agreement with physicians providing in-network care at UVM Medical Center could leave its members without a treating physician. If fewer members are getting in-network care, it would increase profits further for UnitedHealth.

    UnitedHealth’s members will all have to find new network physicians if United does not reach agreement with the providers at UVM. But, that means that some members in the midst of cancer treatment could be without treatment as of April 1. Notably, people in Medicare Advantage are not affected by these negotiations, likely because the government negotiates provider rates for people with Medicare, and Medicare Advantage plans can piggyback off those rates for their Medicare members.

    UnitedHealth claims UVM provider rates are rising too much. UVM, in turn, says that it is facing rising staffing and other costs and needs higher rates to survive. It adds that administrative and other operational barriers UnitedHealth imposes keeps patients from getting the care they need in a timely fashion. “Despite our best efforts to resolve these issues, patients continue to experience unnecessary delays in and restrictions on approvals for common tests, imaging, treatments and medications, among other challenges, due to United’s own policies and reimbursement practices.”

    UnitedHealth told one cancer patient currently getting treatment at UVM Medical Center to get her chemotherapy from a hospital 95 miles away. Really? If Congress does not yet deem it appropriate to step in and guarantee everyone access to care, it’s hard to imagine what it will take to move policymakers.

    Here’s more from Just Care:

  • How to prepare for your doctor’s visit

    How to prepare for your doctor’s visit

    Whether you’re in good health or poor health, in a separate post I explained why it’s important to have a good primary care doctor. And, I’ve provided four questions to help you know whether your primary care doctor is meeting your needs. Here, I want to help you prepare for your doctor’s visit, so that you make the most of it.

    1. Confirm that your doctor accepts your insurance. If you have traditional Medicare, ask if the doctor accepts assignment, which means that the doctor accepts Medicare’s rate as payment in full. If you have a private insurer such as Aetna or Cigna, to save money, make sure the doctor is in-network. Always find out how much more you may have to pay out-of-pocket.
    2. Ask a family member or person you trust to join you. No matter what your age, it’s always good to have a health care buddy, a second pair of ears to listen to the doctor’s advice and, ideally, to take notes. You may also want your buddy to ask questions. The doctor’s visit can be stressful. You can decide to have your buddy be present for some or all of the visit – you are in charge!
    3. Make sure you bring a list of your medications with you, both prescription drugs and over the counter. And, ask your doctor whether you should be taking all these drugs.  It may be that you don’t need to be on a drug or that one drug you’re taking interacts poorly with another one. As you collect the bottles, think of any concerns, side effects or questions you have about your treatments.
    4. Make a list of all the questions you have for your doctor and other information you want to share, including any symptoms and concerns you have about your health. [Editor’s note: If you go alone to the visit, be sure to bring a pen and paper to take notes and repeat the doctor’s advice in order to confirm that you understand it.]
    5. If it’s your first appointment, you want to be sure to let your doctor know about any chronic conditions and any other health problems you have, as well as diseases that run in your family. If possible bring past medical records, test results, and your immunization records. You can ask the last doctor you saw to provide this information to your doctor, or you can sign a release form to have your new doctor’s office request your prior records.  If you are already an established patient of the doctor, be ready to provide your doctor with any major family health updates—for example, if your brother has been recently diagnosed with high blood pressure, or a parent was diagnosed with cancer.
    6. Check with the office if you are expected to come on an empty stomach to your appointment. There are only a few tests that need to be done in the “fasting state” (meaning, no food or drinks other than water for 12 hours). If you are expected to be fasting, tell the office if you are taking medications that require food, or if you think this will be difficult for you for any reason. Remember that most routine tests are not affected by drinking water, but being dehydrated could lead to slightly abnormal results.
    7. If your doctor is suggesting a test or treatment, to avoid overtreatment, be sure to understand why you need it. What are your options? How will it help? Are there side effects?
    8. Be sure that when you leave the office you understand your diagnosis and what you need to do, as well as when and how to contact the doctor and when to make another appointment. If you need a new prescription, make sure you know when to take it and what to do if you experience any side effects.

    [Editor’s note: This post was originally published on June 29, 2016.]

    Here’s more from Just Care:

  • Beginning January 2022, HHS bans surprise bills from out-of-network providers

    Beginning January 2022, HHS bans surprise bills from out-of-network providers

    HHS has issued an interim final rule that bans surprise bills for patients who receive care from out-of-network providers at in-network hospitals. The rule applies to both emergency and non-emergency care, reports Joyce Frieden at Medpage Today.

    Many patients find, even when they are careful to see in-network doctors at in-network hospitals, that they receive care from a range of 0ut-of-network providers as well. Radiologists, anesthesiologists and emergency doctors are three types of specialists that often do not provide in-network care. With this new HHS rule, patients will only pay the in-network copay for out-of-network services in in-network hospitals.

    The HHS rule builds on Trump administration policy. It bans surprise medical bills as well as high charges from out-of-network providers for non-emergency care for which people have no advance notice. These are unexpected charges because they are either buried in the fine print from an insurer or are left out.

    People who receive out-of-network services in non-emergency situations need to have notice and give their consent. As it is, when patients are billed for out-of-network care, their out-of-pocket payments generally do not count towards their deductible or their out-of-pocket cap.

    The HHS interim final rule also forbids insurance companies from retroactively denying emergency room visits, reports Robert King for Fierce Healthcare. In essence, insurers cannot second guess individuals as to whether they experienced an emergency after they receive emergency services. Insurers must pay these claims.

    HHS plans to issue a series of other interim final rules in the next several months. It will be requiring better price transparency for consumers as well as better tools for comparing provider charges. HHS Secretary Xavier Becerra wants these rules to be crystal clear and understood by all parties so that they actually work in practice and not simply in theory. Time will tell.

  • Do Medicare Advantage plans give you appropriate access to doctors?

    Do Medicare Advantage plans give you appropriate access to doctors?

    Most Medicare Advantage plans establish networks that restrict your access to doctors and hospitals. And, the data show that people in Medicare Advantage plans overall have a greater chance of getting care from lower quality providers than people in traditional Medicare. A new paper by David Meyers et al. in the Journal of General Internal Medicine finds that Medicare Advantage plans with five-star ratings tend to have narrow networks that restrict access to certain types of care considerably.

    Here’s what some of the independent research reveals: People enrolled in Medicare Advantage are less likely to receive care from the highest quality hospitals and nursing homes and are more likely to disenroll if they develop a complex condition. Black, Hispanic, and Asian Americans enrolled in Medicare Advantage plans have poorer health outcomes than white Americans. It’s not clear, however, whether this racial disparity stems from the makeup of the Medicare Advantage plan networks.

    In their new research, Meyers and his team find a correlation between plans with higher star-ratings and the breadth of their provider networks. They find that the big for-profit health insurers offering Medicare Advantage plans with higher premiums and a large number of enrollees have wider networks. And, they find that Medicare Advantage plans with the highest star ratings tend to have narrow networks.

    Furthermore, the researchers find that if you’re in a Medicare Advantage plan, odds are that you’ll have inadequate access to in-network mental and behavioral health providers, cardiologists, psychiatrists, and primary care providers.

    Note: Star-ratings do not tell you enough about the quality of a plan to rely on. You can’t don’t know which Medicare Advantage plans give you access to high-quality providers. That’s inexcusable.

    The researchers argue specifically for more information to people choosing among Medicare Advantage plans about the breadth of their provider networks and reforms that ensure adequate numbers of mental health providers in Medicare Advantage plan networks.

    All said, you can’t possibly look at the available information and choose a Medicare Advantage plan that’s right for you. You don’t know enough about what the Medicare Advantage plan offers or what your future health care needs will be. Only traditional Medicare allows you the freedom to meet those needs when and where you choose.

    Here’s more from Just Care:

  • Surprise! Congress supports legislation to protect Americans from unexpected medical bills

    Surprise! Congress supports legislation to protect Americans from unexpected medical bills

    The Hill reports that Democrats and Republican members of Congress are coming together over legislation that would protect some people from unexpected medical bills. Too often, Americans are going to the emergency room and finding themselves with thousands of dollars of medical bills they thought their insurance would cover. The proposed legislation would be beneficial, but only address the tip of the commercial health insurance iceberg.

    Here’s the heart of the problem:

    1. Congress does not regulate health care prices.
    2. Congress allows commercial insurers to restrict their coverage to a limited group of medical and hospital providers.
    3. And, Congress does nothing to protect, or require insurers to protect, people with insurance who are seen unknowingly or in emergency situations by providers who are not in their insurers’ networks.

    Medicare for all, improved and expanded Medicare, would address all these problems at once. Medicare for all does not mean Medicare for some.

    In our current commercial health insurance system, insured individuals can and do get billed tens of thousands of dollars if they end up receiving out-of-network care even in emergency situations. One insured teacher in Texas received a bill for $108,951 after a heart attack. And, the problem goes beyond emergency situations to situations in which individuals receive in-network hospital care but receive out-of-network doctor care, which is outside their control.

    It is not at all clear how often people enrolled in Medicare Advantage plans are faced with surprise medical bills. If you are enrolled in a Medicare Advantage plan, you should be protected against balance billing by out-of-network providers.

    For people not enrolled in Medicare, in the US House, Congressmen Frank Pallone(D-NJ) and Greg Walden (R-OR) propose turning responsibility for handling unexpected medical bills to providers and insurers, taking patients out of the middle in emergency situations. This would be a big step forward for patients. But, insurers and providers may try to derail the bill if insurers feel they would be expected to pay more than they think appropriate or providers feel they would be expected to accept lower rates than they think appropriate.

    In the Senate, Senators Bill Cassidy (R-La.), Maggie Hassan (D-NH) and Michael Bennet (D-CO) are working on legislation as well. A Senate bill was in play last October. With Congress, even small important bi-partisan fixes can take way too long.

    Here’s more from Just Care:

  • Don’t trust your health plan’s provider directory

    Don’t trust your health plan’s provider directory

    Traditional Medicare’s “one size fits all” approach offers a wide choice of doctors and hospitals at a predictable cost, for which you can budget. With commercial insurance, be it through a Medicare Advantage plan, a state health care exchange, or your employer, your choice of doctors and hospitals can be quite limited; and you may not be able to see the doctors you want to see. Beyond that, you can’t trust your health plan’s provider directory to reflect accurately the doctors you can use or the locations at which you can get care.

    If you’re looking to see certain doctors, a plan’s provider directory may list them as part of their network, but the doctors may not be in your health plan. And, if the doctors are in your health plan, they may not be taking new patients from your health plan. Or, the doctors may only be seeing patients from your health plan at a location that is inconvenient for you, which is different from the location listed in the directory. (Here are two tips to help you choose a health plan.)

    To address problems with health plan provider directories and help people make better decisions about their health plans, CMS imposed rules on health plans that became effective in 2016. Both Medicare Advantage plans and plans in the state health exchanges must publish up-to-date provider directories, including which doctors are seeing new patients, their locations, contact information, specialties and hospital affiliations. And, in addition to making them easily accessible, they must keep them updated each month. Three years later, the rules are not working.

    CMS may impose penalties on Medicare Advantage plans up to $25,000 per person enrolled if they violate the rules and up to $100 per enrollee on health plans in the state exchanges. These penalties should deter plans from listing doctors in their directories who have left their plans as much as ten years back, as some have been doing, but they have not. (In November 2014, California levied penalties of $250,000 each on Blue Cross of California and Anthem Blue Cross because 25 percent of the doctors they listed said they did not accept these plans or did not offer services at the listed locations.)

    The Washington Post reports that for the third year in a row a CMS audit found that more than half of the Medicare Advantage plans have at least one deficiency in their provider directories–mistakenly telling people that doctors are in-network when they are not or that they are taking new patients when they are not or that they are seeing patients at particular locations when they are not. Yet, the Trump Administration has chosen not to fine Medicare Advantage plans that violate these rules.

    If CMS were to use its power to impose fines on Medicare Advantage plans, Medicare revenues could be way up. One recent CMS investigation found that the online directories of 54 Medicare Advantage plans had incorrect information on more than 2,500 of the 5,832 doctors listed. 

    Since you can’t trust the provider directory, how can you help ensure you see in-network doctors?

    1. Talk to the staff of the doctors you use to see what plans they are in and whether you will be able to see them in-network.
    2. Keep in mind that three out of ten doctors change their hospital affiliations or practice group each year.
    3. Insurance contracts can be so complex that sometimes staff don’t know what plans the doctors are in. Always call your health plan to double check.
    4. Finally, make sure that whatever plan you join has a stable of good specialists. Even if you’re healthy, you want to know that there are doctors in the plan who will meet your needs if you develop a costly or complex condition. (Indeed not knowing your future health care needs makes it challenging to choose a health plan that’s right for you.)

    Unfortunately, it’s still hard to avoid medical bills from providers who are not in your plan’s network if you are hospitalized. Often the in-network hospital has teams of out-of-network doctors.

    Congress is now looking to address the problem of these “surprise medical bills.” Twenty-five states have already passed laws offering people some protection against these surprise bills.  The best way to protect yourself is to let the hospital know in advance of being admitted that you only want to be treated by in-network doctors.

    To learn more about Medicare Advantage plan networks and provider directories, there’s a September 2015 report by the Government Accountability Office (GAO) critiquing CMS oversight of Medicare Advantage plans to ensure adequate access to care in the wake of United Health terminating contracts with well over 1,000 Medicare Advantage providers in 24 states. Medicare Advantage plans can end contracts with doctors and other providers at any time for any reason. The GAO recommended heightened CMS oversight of Medicare Advantage plans and rules to help patients accurately understand health plan provider networks.

    Here’s more from Just Care:

  • Don’t rely on Medicare Advantage plans to cover care from doctors you can trust

    Don’t rely on Medicare Advantage plans to cover care from doctors you can trust

    There is not a lot of good information available to help you choose a doctor, whether the doctor is a primary care doctor or a specialist. Yet, particularly when you’re ill or injured, it is important to be able to count on good primary care doctors and specialists. Unfortunately, you cannot rely on Medicare Advantage plans–commercial health plans that contract with the federal government to provide Medicare benefits–to cover care from doctors you can trust, let alone from the doctors you want to see.

    A recent Pro Publica report highlights how a Medicare Advantage plan had a neurosurgeon in its network who was critically harming and sometimes killing his patients. Lesson learned: It is a mistake to assume that Medicare Advantage plans ensure the quality of the doctors with whom they contract to provide in-network care.

    It is also a mistake to assume that Medicare Advantage plans offer you the choice of doctors you want to see. A Kaiser Family Foundation report found that more than one in three Medicare Advantage plans offer narrow networks, meaning less choice of doctors and hospitals. They typically include fewer than half of all doctors in a region.

    Medicare Advantage plans also typically cover care at only half the hospitals in their area, according to the Kaiser Family Foundation. What’s particularly troubling is that they too often do not cover care at centers of excellence. Even when there is a national cancer institute in the area, more than 40 percent of Medicare Advantage plans do not cover care delivered in that specialty hospital.

    Fewer than one in four Medicare Advantage plans offer broad networks, covering care in 70 percent of area hospitals.

    It’s critical to do your homework before deciding to join a Medicare Advantage plan. Traditional Medicare may require higher upfront costs than Medicare Advantage plans–particularly for people who need to buy supplemental coverage. But, traditional Medicare offers coverage from a wide range of doctors and hospitals throughout the country; and, you do not need a referral from a primary care doctor to see a specialist. Moreover, with supplemental coverage, you generally have no or small out-of-pocket costs for covered services. Out-of-pocket costs for in-network care in a Medicare Advantage plan can easily reach $6,700 a year for people with costly conditions. And, the sky’s the limit on your out-of-pocket costs if you use out-of-network care.

    No matter which Medicare plan you are enrolled in, be sure to choose your doctors carefully, a challenging task. Keep in mind that hospitals may employ surgeons who are not fit to be practicing medicine. They may not report surgeons who they know to be hurting their patients. And, these doctors may do serious harm.

    Here’s more from Just Care:

  • Could government price caps on out-of-network care lead to lower health care costs?

    Could government price caps on out-of-network care lead to lower health care costs?

    A new working paper from the Congressional Budget Office (CBO) shows that a government price ceiling on out-of-network care allows Medicare Advantage plans (commercial health plans that offer Medicare benefits) to contain in-network provider rates and keep premiums down. Would government price caps on out-of-network care for commercial health plans that provide coverage to working people lead to lower health care costs for in-network care as well?

    In brief, the CBO finds that Medicare Advantage plans pay providers close to the same amount as traditional Medicare, for which the government negotiates provider rates. Medicare Advantage plans are able to secure favorable doctor rates principally because doctors know that the traditional Medicare rate is the most Medicare Advantage plans are responsible for paying them for out-of-network services under the law. Moreover, doctors know that the traditional Medicare rate is the best rate they can get for treating people with Medicare not enrolled in a Medicare Advantage plan.

    In stark contrast, commercial health plans offering coverage to working people, pay on average as much as two times traditional Medicare rates for the same services. Doctors in many communities appear to have a lot of negotiating leverage with commercial health insurers. As a result, unlike traditional Medicare and Medicare Advantage plans, commercial health plans covering working people pay very different doctor rates both within geographic areas and among geographic areas.

    It is due time that Congress stepped in to rein in provider rates for everyone. As it is, one in four working people with health insurance skip care because of its cost, And, taxpayers are supporting these excessive provider rates. Taxpayer dollars subsidize the cost of commercial insurance both for people with workplace coverage and for people in the state health insurance exchanges. People with workplace coverage get preferential tax treatment for that coverage. And, many people in the state health insurance exchanges get taxpayer subsidies for their premiums and cost-sharing.

    With Medicare for all, as Bernie Sanders and 15 other Senators have proposed, Congress could ensure fair provider rates and lower premiums for everyone. Simply placing a cap on the amount commercial insurers pay for out-of-network care, as some have proposed, would not likely give commercial insurers the needed leverage to bring down provider rates. Providers would likely still have the leverage to raise their rates further for in-network care to compensate for the loss in revenue from out-of-network services. Similarly, extending Medicare to people without workplace coverage and allowing commercial insurance to continue for people with workplace coverage likely would not give the commercial insurers the needed leverage to rein in provider rates. Only about 10 percent of services are out-of-network.

    Providers have extra leverage over commercial insurers in the non-Medicare market because commercial insurers can pass on costs to businesses buying the health care coverage. It is hard to see providers conceding voluntarily to lower rates for people who have always paid more for their care than people with Medicare. We need Congress to extend Medicare to everyone in order for everyone to benefit from Medicare’s rates.

    If you agree that it’s time for Congress to allow Medicare drug price negotiation, please sign this petition.

    Here’s more from Just Care: