It is becoming increasingly difficult to make financial statements when carriers are making modifications to the networks on an ongoing basis. This article highlights some of what is occurring nationwide. It becomes increasingly important to be able to do financial modeling rapidly and accurately on a "what if" basis. Many of the physicians who receive notifications from UnitedHealth will need to be changing their employee and physician makes if they have significant portions of their patient revenue from this carrier. We have already found some physician and physician group clients who have had to make short-term (less than six months) changes in their physician and physician extender employees based on gains and losses from the Affordable Care Act and related network changes.
Published Date: June 17, 2014
By: Rachael Zimlich
A new wave of physicians are being cut from UnitedHealth Group’s Medicare Advantage network, continuing a trend that started last year and has reportedly already shaved more than 30,000 physicians from the same network.
UnitedHealth started notifying physicians who are being terminated from the network over the last few weeks, according to state medical associations in states such as Alabama, Georgia, Massachusetts, North Carolina and Tennessee.
Massachusetts’ medical society reports that 2% to 4% of physicians in its Medicare Advantage network will be cut by United as of September 1, but none in the Boston or Middlesex areas. Georgia is reporting a 10% reduction by September 1 as well, while Tennessee’s medical association says 500 doctors are expected to be cut from that state’s network as early as August 15.
Minnesota-based UnitedHealth hasn’t confirmed exactly how many physicians they will cut nationwide, but press releases have indicated the end goal is to reduce networks by 10% to 15% below last year’s levels.
In an emailed statement on the cuts, UnitedHealth spokesman Terence O’Hara says the company will make sure that any members changing physicians have individual courses of treatment and that their ongoing care needs are not disrupted.
O’Hara did not reveal specifics as to how the insurer determined which physicians it would terminate from the network. “Our physician network should have the ability to improve healthcare outcomes, enable more collaboration with providers, and encourage more use of primary care,” O’Hara wrote.
“When making decisions about the composition of our Medicare Advantage networks, we focus on ensuring that our members will have ready access to care and also consider providers’ ability to work with us to improve the quality of a member’s health care experience in the most cost-efficient manner. Among the many factors that we consider are the relative breadth of our network in a particular market, the access and health care needs of our local membership, the number of UnitedHealthcare members seen by a provider, as well as the type of contract we have with that doctor,” he added.
UnitedHealth began cutting its networks last year in Connecticut, Florida, New York, Ohio, and other states. Connecticut challenged the reductions in court, filing an injunction and eventually winning an appeal that established an appeals and arbitration process for physicians who have been cut from the network.
According to the Tennessee Medical Association (TMA), the cuts are part of a larger plan by UnitedHealth to consolidate patients into larger practices and are “not for cause” terminations that do not need to be reported to the National Practitioner Data Bank.
“UHC will not, in the letters or if contacted, give physicians a reason for their termination,” TMA says.
The TMA outlines a process for appealing the terminations on its website, and says letters United sends to terminated physicians should also include a detailed appeals process.
The American Medical Association (AMA), along with 81 other medical groups, including the American College of Physicians and American Osteopathic Association, have said the terminations are “without cause” and have asked the Centers for Medicare and Medicaid Services (CMS) to take action. The AMA also contends that the termination notices were sent in unmarked envelopes as bulk mail and were mistakenly disregarded by many practices. “As a result, many physicians do not know and have not been able to determine whether they are still in plans,” it says.
Some physicians report that some Medicare Advantage sponsors are not providing “the affected physicians with written notice of the reasons for the action that includes, among other things, the standards and profiling data used to evaluate the physician and the numbers and mix of physician needed by the Medicare Advantage organization,” the AMA reports.
Source: Medical Economics