Humana Medicare PPO members lose in-network access to Memorial Healthcare system as contract disputes disrupt patients [South Florida Sun-Sentinel]
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That left Karr with two unappealing choices — stay with her preferred surgeon and pay sky-high out-of-network rates, or hunt for another surgeon at another in-network hospital willing to perform the procedure.
“I had a virtual nervous breakdown,” Karr said Tuesday. “I set the appointment two months eariler and had gone through all the preparation, had medical tests, examinations, and gathered my medical records.”
Karr is just the latest
On the same day, at least 13,000 members of UnitedHealthcare’s various insurance plans lost in-network access to Broward Health’s facilities. And on
Tense contract negotiations between insurers and providers are nothing new. In recent years, similar fights spilled into the public arena involving
All were resolved within weeks of contract expirations, with insurance plan members’ in-network coverage reinstated retroactively.
Similar resolutions could still take place if the latest standoffs are resolved in coming days or weeks.
But for Karr and other members who need their procedures sooner rather than later, being caught in the middle of disputes between deep-pocketed entities that take in multiple millions of dollars a year can be infuriating.
When interviewed by phone on Tuesday, Karr was on her way to an appointment with another physician she hopes can perform the surgery at in-network rates, and she plans to see yet another physician in two weeks.
“Unfortunately, the surgeon I have a relationship with and who I truly wanted to operate on me has hospital privileges limited to
Even more maddening, she said, is that members of Humana’s
Generally, PPO plans provide more flexibility by enabling members to make appointments with in-network specialists without referrals from their primary care doctors, while HMO plans tend to cost less for members while offering a more narrow list of providers. In an HMO plan, members cannot see specialists without a referral from their primary care doctor.
Karr said she is unable to switch from her PPO plan to an HMO plan that includes her preferred surgeon because switches are only allowed during open enrollment periods. This year, open enrollment for Medicare Advantage plans ended
A Humana spokeswoman said the insurer sent letters to about 400 members who had used
Karr said she never received a warning letter. “If I had received it, I would have had plenty of time to resolve this by switching to the HMO plan.”
Contract cancellations stranding more consumers
Neither Humana nor
But typically such disputes — if the sides decide to air their grievances publicly — come down to insurers complaining that hospital systems are seeking excessive rate increases that would have to be passed along to individual members and employers that fund group coverage, and hospitals complaining that the insurer refuses to agree to the same rate terms that other insurers have accepted.
High-stakes hardball negotiations are not unique to
Across the country, more and more disputes are resulting, at least temporarily, in contracts allowed to lapse and members stranded without in-network access to physicians they’ve been seeing for years, according to a November report by
More recently,
Last year, contracts between major hospital companies and either
Hospital systems flexing their muscles?
The region has too many hospital beds for the number of residents, she said. Excess capacity raises costs for hospitals because they still have to have their own buildings, state-of-the-art equipment, executives, doctors and nurses and everything else needed to run hospitals, regardless of how many or few patients they serve, she said.
“By having too many competitors for the same pool of sick people, it raises prices because the inputs are still there,” Quick said. “If they are underutilized for any reason, costs go up.”
Some hospital systems are operating their own Medicare Advantage plans and wouldn’t mind absorbing other insurers’ stranded members.
“Particularly with the Medicare Advantage business line, those providers believe that they control access to the patients,” Baumgarten said in an email. “Medicare Advantage enrollment has been growing steadily, and more plans try to enter local markets every year.”
Consumers tend to stay with the first plan they select at open enrollment time, he said, “so it’s especially important to
Hospitals contend that they are facing the same inflationary pressures as everyone else in the economy.
In its November story,
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