This Miami health system could go out-of-network with United. What it means for you

South Florida patients insured through UnitedHealthcare could be locked out of in-network care at the University of Miami Health System as soon as August if a deal isn’t made soon.

UHealth is sounding the alarm over its ongoing contract negotiations with UnitedHealthcare, the largest health insurer in the country with millions of members. It’s accusing UnitedHealthcare of not paying its doctors enough for care and “putting profits ahead of South Floridians’ care.”

UnitedHealthcare, whose parent company is UnitedHealth Group, meanwhile, is accusing UHealth of seeking “significant price hikes that would increase health care costs for families and employers.”

The two have until July 31 to reach a deal. If they don’t, UHealth will become an out-of-network provider starting Aug. 1.

This is the latest South Florida hospital versus health insurer dispute to go public. Thousands of people insured through Florida Blue, one of the largest health insurers in the state, are still out-of-network at Broward’s two public hospitals due to stalled contract negotiations. Broward Health and Memorial Health have accused Florida Blue of not paying them enough for care, while the health insurer is accusing them of wanting too much money. Negotiations remain ongoing.

Here’s what else to know:

If the two parties can’t make a deal, then UHealth hospitals, facilities and physicians will be out-of-network starting Aug. 1 for patients who have health insurance through UnitedHealthcare’s network. The health insurer said that includes employer-sponsored commercial plans, Medicaid (UnitedHealthcare Community Plan of Florida) and Individual Family Plans (IFP), which are health insurance plans a person purchases on their own, usually through the Affordable Care Act (ACA) marketplace.

Patients enrolled in UnitedHealthcare’s Medicare Advantage Preferred Care Network plan would still have access to UHealth facilities and doctors due to a separate agreement, according to UnitedHealthcare.

If UHealth goes out-of-network, patients will either have to search for a new in-network doctor or get stuck paying a heftier bill out of pocket to continue getting care with their UHealth specialists, including at Bascom Palmer Institute, which has long reigned as the top hospital for eye care in the nation, and Sylvester Comprehensive Cancer Center, the only National Cancer Institute-designated cancer center in the region.

It’s not clear how an out-of-network UHealth would affect, if at all, the ongoing partnership between UM’s medical school and Jackson Health System, Miami-Dade’s public health system, which has long served as UM’s teaching hospital. Jackson and its Miami Transplant Institute, for example, use doctors from the University of Miami Health System.

It’s worth noting that if UHealth were to go out-of-network, patients who are undergoing treatment for serious or complex conditions, such as people who are pregnant or are currently undergoing active cancer treatment, would be eligible to continue receiving in-network care with UHealth for 90 days due to a federal law that requires insurers to provide continuity of care.

“UnitedHealthcare members must apply and be approved for continuity of care. People can apply at any time from now through 30 days after a provider has left our network,” UnitedHealthcare wrote on a webpage about the ongoing negotiations. “They should call the number on their health plan ID card if they need assistance or have questions.”

The good news is that UnitedHealthcare, like most health insurers, is required by law to cover emergency care at UHealth and other ERs at in-network rates, even if the emergency room is out-of-network.

It doesn’t matter if the patient is hospitalized or goes home the same day. If it’s an emergency, health insurance will cover it at in-network rates, according to Patricia Kelmar, senior director of healthcare campaigns at PIRG, a nonprofit that advocates for consumer protections, public health and environmental sustainability.

But beware: ER doctors decide the necessary treatment, but it’s the health insurer that ultimately determines whether the provided services fall under emergency care for in-network rates, Kelmar previously told the Miami Herald.

TIP: ERs are meant for life-threatening or potentially life-threatening symptoms and conditions, such as if you’re struggling to breathe or have chest pain or numbness on one side of the body. Urgent care is the place to start for everything else, like a cough, sore throat, runny nose or diarrhea. Urgent care visits are also cheaper.

Hospitals and health insurers undergo contract negotiations all the time. Sometimes, those disputes go into the public eye.

“While the cost of healthcare, nurses, and medical supplies keeps going up, UnitedHealthcare is not reimbursing at rates that keep pace. We need United to agree to a new agreement so UHealth can continue delivering the high-quality care patients and families rely on from the region’s only academic medical center,” UHealth wrote on a webpage about the ongoing negotiations.

“United made $9 billion in profits in just the first three months of this year, but they refuse to pay UHealth the same rates they already pay other hospitals in South Florida,” said the health system. “This isn’t just happening here. Across the country, United has repeatedly put profits ahead of patients’ access to care in other negotiations.”

It’s not just reimbursement rates that have UHealth fuming. The health system says it’s also fed up with the “delay and deny care” tactic the health insurer uses, despite 94% of the denials later being overturned and approved.

“These unnecessary delays take valuable time away from care teams — time that should be spent caring for patients, not battling red tape,” UHealth wrote.

UHealth has also pointed to a proposed policy by United that it claims “could force patients receiving ongoing infusion treatment, such as chemotherapy, to leave UHealth in the middle of their care.”

UnitedHealthcare, on its own negotiation webpage, said it negotiates thousands of contracts each year and while “the vast majority are resolved with no disruption to in-network care” some health systems, like UHealth, “choose to negotiate publicly, putting their patients in the middle of these discussions as potential leverage to obtain the price increases they are seeking.”

UnitedHealthcare, in its post, explained that “health care costs are directly affected by the reimbursement we negotiate with health systems in our network” and that “one of the leading drivers of rising health care costs are the prices hospitals charge.”

And the rates UHealth wants are just too costly, according to UnitedHealthcare.

“We are proposing rate increases that continue to reimburse UHealth similar to its peers throughout the region while balancing the need for affordable care for hard-working families and employers already struggling during challenging economic times,” the health insurer wrote.

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