5,000 Medicare patients shut out from Austin Regional Clinic

Sept. 21--A contract dispute between Austin Regional Clinic and UnitedHealthcare has left an estimated 5,000 Medicare patients without access to their physicians, according to clinic officials.

Patients who are enrolled in UnitedHealthcare's Medicare Advantage plan were notified through mail by the insurance company last week that Austin Regional Clinic would no longer be in their network starting next year, clinic officials say. However, patients received another letter from the company that said as of Oct. 1, they had been assigned a new physician with a provider group that UnitedHealthcare owns and manages.

Norman Chenven, founding chief executive officer of Austin Regional Clinic, said that UnitedHealthcare also prematurely kicked Austin Regional Clinic physicians out of the insurance company's computer system and effectively, out of its network, violating terms of their contract.

"This was a sneak attack," he said. "We love United, but what they have done in this instance is really what we believe is extremely bad form because they're jeopardizing people's health care by introducing a lot of confusion and fear. Some of these patients have been with our doctors for 38 years, many over 30 years. For them to get letters saying as of Oct. 1, you can't see Dr. Merryman anymore and you have to see Dr. Jones who you've never heard of and you don't know where his office is, that's crazy and there was no reason for that."

Clinic officials say UnitedHealthcare has reinstated Austin Regional Clinic's physicians into the insurance company's system through Dec. 31, but the physicians are listed as inactive and they have not been reassigned to patients, according to the clinic. In the meantime, UnitedHealthcare has provided Austin Regional Clinic with a temporary telephone line so that clinic staff can call to get referrals and services approved on a case-by-case basis for UnitedHealthcare Medicare Advantage patients.

UnitedHealthcare officials dispute the clinic's claims, saying the clinic was not terminated from the network early and referred to the letters sent to patients that said patients need only to call the number on their insurance card to notify the company they wish to stay with Austin Regional Clinic. UnitedHealthcare officials blame the clinic for choosing to sever ties in the first place.

Control over patient claims

During contract negotiations, Austin Regional Clinic wanted UnitedHealthcare to provide more direct access to patient claims for services that occurred outside of the clinic. The clinic wanted to use its own technology to process those claims, and UnitedHealthcare wanted to use its own. After several months, negotiations fell through.

This dispute does not affect non-Medicare patients, and the clinic will continue to accept commercial UnitedHealthcare plans.

"The reason ARC decided to leave UnitedHealthcare's network is not because they couldn't access patient claims. ARC has always had access to claims data for services that they render to their patients. ARC wanted to leverage a third-party organization's technology for processing patients' claims. UnitedHealthcare already has this capability locally in Austin, which UnitedHealthcare offered ARC," said UnitedHealthcare spokesman Dustin Clark.

The clinic receives claim reports from UnitedHealthcare six months after services have been delivered, which is too late, Chenven said. The clinic insists on using its own technology because its physicians don't want to have to use multiple platforms. Three other Medicare Advantage plans have agreed to use the clinic's technology, Chenven said.

"If you know all of what's happening to a patient ... and it's all in the claims ... and if you have sophisticated ability to analyze it, you can provide much better care," Chenven said.

Chenven said UnitedHealthcare's decision to prematurely move patients to another provider group has affected patients' access to prescription drugs, specialists and surgeries because their primary care physicians, who often write such referrals, are no longer considered in-network.

'It's truly scary'

The Austin Regional Clinic has about 12,000 patients on Medicare Advantage. Instead of the federal government administering the program as it does in traditional Medicare, services under Medicare Advantage plans are delivered through private insurance companies. The federal government oversees the companies.

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Central Texas patients also have run into problems with Medicaid, a government-subsidized program for low-income and disabled children and adults. In recent months, at least four Austin-area providers had notified their patients they would stop serving children with Blue Cross and Blue Shield of Texas Medicaid plans after complaints that the managed care organization had failed to pay the providers for certain services, among other problems. Amid complaints to lawmakers and the media, the company resolved the issues with the four provider groups, which continue to accept Blue Cross and Blue Shield of Texas Medicaid plans.

Chenven said since last week, Austin Regional Clinic has received hundreds of calls from Medicare Advantage patients confused by the change. One of them was 88-year-old Northeast Austin resident Wanda Lemons, who said she panicked after being notified of the change. She and her 90-year-old husband, Donald, who has late-stage Parkinson's disease, have been seeing Dr. Michael Prete at Austin Regional Clinic for 20 years. Among other health problems, Lemons has Von Willebrand disease that prevents her blood from clotting properly.

"I'm being told what insurance I have to have and what doctor I have to go to. I have no right," Lemons said. "It's scary. It's truly scary. If I were to have an emergency who would I go to? I don't know this doctor, but most of all, she doesn't know me to what I need."

Clark said the Lemons have access to nearly 8,500 providers in Central Texas, including all the local hospitals, through their UnitedHealthcare plan.

"In the meantime, we remain committed to working with ARC over the next few months to ensure members have seamless transition of care," Clark said.

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