Beginning in October, notices have been mailed to physicians by United Healthcare (UHC) providing a 90 day notice of termination from their Medicare Advantage (MA) networks in at least 10 states. Physicians have 30 days to appeal the termination and instructions are included with the letters. These terminations will result in a 10%-15% reduction in the size of the United Healthcare MA network nationally. Lawmakers and medical advocacy groups from several states including Connecticut and New York are attempting to have providers reinstated or at the very least, compel UHC to disclose how physicians were selected for termination or to provide assurances that there will be appropriate access to care for the MA members. Other carriers with MA networks such as Blue Cross Plans and Humana have taken similar measures and others are expected to follow suit. Approximately 27% of Medicare recipients are enrolled in a MA product.*
Regardless of the outcome of the current UHC provider network reduction, let’s take this opportunity to review some practical action steps. First, “How can they do this?”. How can they do this? There is standard language in most payor contracts to permit the plan make changes in their networks without a provider having to sign an amendment. The language will vary by state and plan. Plans must adhere to CMS and state regulations governing provider rights, but will retain the ability to make changes to respond to business needs quickly and without requiring a provider’s signature. Plans with Medicare Advantage and Medicaid products generally have contract Appendices with regulatory requirements relevant to the programs.
For example, in New York, a plan is not permitted to terminate a provider without cause, rather they are required to provide notice of non-renewal of the agreement upon the anniversary date of the contract. The recent New York UHC terminations were not really terminations at all, rather a network was being removed from their contract by unilateral amendment. The provider has the option to accept the amendment as offered, terminate the agreement if the amendment is unacceptable (leaving the provider as non-participating entirely), or can be offered an appeal. In this case, providers were given 30 days to file an appeal. How does a Provider appeal? Read the correspondence or your contract carefully and draft a professional letter explaining why your practice is critical to the plan’s Medicare Advantage population. Is there a geographic or transportation need being met? Do you offer a specialized or cost-efficient service to the MA population? Do you have foreign language or translation services perhaps required for your community. Dig deep and present your argument against the termination. Send the appeal letter via a trackable service to insure its receipt. You can cite the number of MA members you have in your practice, but rest assured, the plan has the data it needs. What else should a Provider do? First, begin by compiling a file of current provider agreements for your top payers. If you are signing or e-signing a contract, save a copy of the document. Review the term and termination provisions in each agreement as well as language pertaining to amendments and your rights. Next, make sure the plans have your current contact address. The contact information for formal communications is in each agreement. If a plan has not been notified of a change in your correspondence address, you may not receive notifications related to participation or contract changes and you may lose your network credentialing status or miss an opportunity to appeal as in the above example. Alert your staff not to assume all plan correspondence is junk mail. Finally, if your practice is large or strategically important to payors, request a language modification so that amendments require signatures. This request may not be honored, but can certainly be made prior to signing the agreement. *UnitedHealth Culls Doctors From Medicare Advantage Plans Physicians in 10 States Notified; Insurer Cites 'Funding Pressure' From Federal Government Wall Street Journal online Nov. 16, 2013 By MELINDA BECK