“We are working in good faith with Oxford to reach a new and fair agreement,” the letter said, adding, “Doctors will remain in-network and maintain their appointments with providers. It's necessary,'' he continued reassuringly.
Over the next few months, I received a flurry of communications regarding the dispute from both the hospital and the insurance company. “It was, 'Don't worry, you don't need to worry,'” Feldman told me in an interview.
In late February, the other shoe finally dropped. As of March 1, Mount Sinai will no longer be in network with Feldman's insurance company.
“All of a sudden you have to change all your doctors, which is stressful for you,” Feldman said. These included not only primary care physicians, but also gynecologists, orthopedic surgeons, and physical therapists.
This is one of the most inequitable aspects of health insurance, in a system that often seems designed for dissatisfaction. Patients can only change insurance during the year-end enrollment period or during a “qualifying life event,” such as: Divorce or job change? However, contracts between insurance companies and doctors, hospitals, and pharmaceutical companies (or their intermediaries, so-called pharmacy benefit managers) can change suddenly at any time.
Whether they buy insurance through their employer or on the marketplace, patients typically choose their insurance based on whether it covers the doctors and hospitals they want or the expensive drugs they need; This is especially troublesome for patients. It turns out that certain coverages can lapse at any time during the policy term.
According to a recent report from the Robert Wood Johnson Foundation, pricing battles are intensifying between large, integrated hospital systems and increasingly large insurance companies in a cut-throat market, leading to increased consumer spending. people are at risk. Such contract disputes are rapidly increasing, with the Becker's Hospital Review website reporting that there were 21 conflicts between insurers and providers in the third quarter of 2023, an increase of 91 percent from the same period last year. There is.
For example, in September, a doctor at Baptist Health in Kentucky abruptly terminated relationships with patients enrolled in Humana's Medicare Advantage plan, and a doctor at Vanderbilt Health in Tennessee abruptly terminated relationships with patients enrolled in Humana's Medicare Advantage plans in April. has terminated its contract with Humana Plan. In both cases, patients were rushed to the hospital. Find new doctors in your network who are affiliated with other hospital systems. And experts predict more cancellations in a ruthless market. (This includes more January 1st layoffs each year, but in that case at least the patients who were left adrift have the ability to buy a new plan that covers their doctor and drugs.)
Alison K. Hoffman, a law professor at the University of Pennsylvania, said that even though the act is “probably legal” for now, “the correct human reaction is that this is horrifying.” Mr. Hoffman found a clause embedded on page 32 of his 60-page insurance policy suggesting that the provider and policy could change at any time. he told me.
Hoffman said state and federal regulators have the power to regulate networks of insurance companies and could end the practice. But until now, there has been no federal regulation on “continuity of coverage,'' particularly on how to define it. She said the apparent spike in contract disputes between insurance companies and health care providers may be due to the Hospital Price Transparency Regulation, which went into effect in 2021 and allowed hospitals to compare reimbursement rates with each other. I doubt it.
In fact, Mount Sinai said it was seeking further reimbursement from United because it found that it paid the airline “substantially less” than “comparable institutions.”
Many insurers say they will continue to pay for a period of time after the contract ends (usually 60 to 90 days) or to complete “temporary care”, particularly pregnancy. But in the case of cancer, for example, does that mean one round of chemotherapy or a full treatment that can last for years? If I need to, or if the patient has to leave the licensed therapist, will insurance coverage continue?
Erin Moses, who works at a small nonprofit, found a new therapist she liked after she and her husband moved to California's Central Coast last February. In September, she received a bill from a therapy organization that said it had terminated her contract with Anthem because her insurance company was late in reimbursement, leaving her with an $814 bill.
“It's not that we can't afford it, but my husband and I are trying to save up to buy a house. This is a big change,” she said.
Patients are often left holding the bag without realizing it. When Laura Alley fell from a ladder in September 2020 and needed surgery to repair her broken pelvis, the hospital was in-network, as was the trauma surgeon.
In a post on “Bills of the Month,” a joint project between KFF Health News and NPR where I work (the source of other examples in this article), Alley writes: The group that provided the anesthesia said: “We are in a dispute with our insurance company and as of July 30, 2020, they are no longer in our network.”
She said in a phone interview that she felt like a “pawn.” She said, “I'm working on recovering from a trauma, and I'm caught in the middle of a dispute between a large insurance company and a large group of doctors.''
She and her husband, who own a small construction company, ended up paying “nearly $10,000” for out-of-network anesthesia services. (This type of out-of-network billing to patients would be prohibited by the Anti-Surprises Act, which went into effect in 2022.)
None of this is new to Mount Sinai patient Sarah Feldman, who was an innocent bystander in the dispute between Oxford Health Plans and the hospital system. Ms. Feldman's parents recently received a phone call from their insurance company, Anthem, informing them that their contract with NewYork-Presbyterian Hospital, where Ms. Feldman's stepmother is being treated for breast cancer, could be terminated on May 1. He said he received it.
It's bad for a patient's health and sanity when the care promised in their insurance plan can suddenly disappear in the middle of the year. And regulators could do something about it. Require health care providers and insurance companies to maintain mutual agreements for the entire term of a patient's insurance policy, ensuring that patients are not left in the lurch.
