January 22, 2014

AMA, Medical Societies Fight Mass Physician Cancellations to Medicare Advantage Plans

AMA, Medical Societies Fight Mass Physician Cancellations to Medicare Advantage Plans

By: Daniel R. Verdon

Medical groups are fighting back following mass cancellations of physicians in Medicare Advantage Plans in at least 11 states.

In Connecticut, two medical societies filed a temporary restraining order against UnitedHealth Group after an estimated 2,250 physicians (810 primary care physicians, and 1,440 specialists) were believed to be cut out of its Medical Advantage network next year.

While UnitedHealthcare has not released official numbers of physician cancellations in that state, Bryan Carroll, UnitedHealthcare’s associate general counsel, did confirm its Medicare Advantage network in Connecticut includes 3,000 primary care physicians and 4,400 specialists in correspondence with the state of Connecticut’s Attorney General George Jepsen.

If these estimates are accurate, UnitedHealthcare dumped 27% of the state’s primary care physicians in one move.

The court hearing is slated for Nov. 25, and it could be just the beginning of an escalating fight between payers and providers.

Thousands more physicians in Arkansas, Florida, Indiana, Nebraska, New Jersey, New York, Ohio, Rhode Island, Texas and Utah are believed to have been impacted by recent network cancellations by health insurance companies.

The issue is so volatile, it resulted in a public exchange between UnitedHealthcare and the state of Connecticut Attorney General Jepsen, who is demanding greater transparency in the numbers of physicians and consumers likely impacted by UnitedHealthcare’s moves.

UnitedHealthcare’s Carroll says in written correspondence that there are many factors involved with the decision. “All of them relate to providing a network of physicians who we can collaborate with to help enhance health plan quality, improve healthcare outcomes, and curb the growth in healthcare costs. Decisions about which doctors will remain part of our network can include the number of patients who are covered by our plans, the relative adequacy of our network in a particular market, and the type of contract we have with the doctor.”

UnitedHealthcare is not alone. In fact, another skirmish recently broken out between Humana and Minnesota Attorney General Lori Swanson, who is asking for legal remedy following complaints filed by the state’s senior citizens.

Robert J. Mills, a spokesman for the American Medical Association (AMA), tells Medical Economics that physicians have reported receiving cancellation letters from Blue Cross and Blue Shield plans, Anthem, and Humana. The Medicare Advantage cancellation notices are coming in the face of a seriously debilitated rollout of the Affordable Care Act’s insurance exchange, and widespread insurance cancellations now estimated at impacting some 7 million U.S. citizens.

The AMA, with 81 other medical groups, including the American College of Physicians and American Osteopathic Association, said the terminations were “without cause” and called on Marilyn

Tavenner, administrator of the Centers for Medicare and Medicaid Services (CMS) to address the “lack of Medicare Advantage sponsor transparency on network adequacy.”

“There is widespread evidence that the proposed modification will disrupt long-established patient-physician relationships, interfere with existing physician referral networks, and undermine emergency department coverage in many hospitals. Both the continuity and coordination of care will be negatively affected and treatment of certain types of care commonly provided by a very limited number of sub-specialists may no longer be available within the network,” the letter states.

Just as bad, AMA contends, is 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.”

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,” AMA reports.

AMA is calling on CMS to require Medicare Advantage sponsors to:

  • Provide and document that patients received actual and accurate notice of whether their current physicians will be in the 2014 network.
  • Ensure that patients know that they can retain their physician by choosing fee for service or by choosing a product with an out-of-network benefit if their plan provides one.
  • Provide physicians information needed to challenge network adequacy based on CMS regulations and extend the appeals deadline until physicians receive such information.
  • Direct plans to hold all terminations initiated just prior to or during open enrollment in abeyance for cost year 2014.

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