Sarah Feldman, 35, received her first ominous letter from Mount Sinai Medical last November. The New York hospital system warned of difficulties negotiating a price agreement with United Healthcare, which includes Mr. Feldman's insurer, Oxford Health Plans.
“We are working in good faith with Oxford to reach a new and fair agreement,” the letter said, adding, “Physicians must continue to remain in-network and maintain appointments with their providers.” Yes,” 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 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. Among them were beloved primary care physicians, as well as 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 arbitrators, so-called pharmacy benefit managers) can change suddenly at any time.
Whether they buy insurance through their employer or on the marketplace, patients generally 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% compared to 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 cast adrift can buy new plans that cover their doctors and drugs.)
Alison 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.” Hoffman said he found a clause embedded on page 32 of his 60-page insurance policy suggesting that providers and policies could change at any time. .
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 attributed the apparent spike in contract disputes between insurers and providers to the Hospital Price Transparency Regulation, which went into effect in 2021 and allowed hospitals to compare reimbursement rates with each other. I suspect that it is.
In fact, Mount Sinai said it was demanding better reimbursement from United Healthcare because it found that the company paid “significantly less” than its “peer 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 so, or if a patient must leave a qualified therapist, is there continuity of coverage?
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 her treatment organization saying that her contract with Anthem had been terminated 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 Bill of the Month, a joint project of KFF Health News and NPR (the source of other examples in this article), Alley wrote: “What I had no way of knowing,” she said about anesthesia, “was that we were in a dispute with our insurance company, and as of July 30, 2020, our insurance company was no longer in network.”
She felt like a “pawn,” she said. “I'm working on recovering from a trauma, but 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 Feldman, a Mount Sinai patient who was an innocent bystander in the dispute between Oxford Health Plans and the hospital system. Recently, Ms. Feldman's parents called her and told her that their insurance company, Anthem, may terminate her contract with NewYork-Presbyterian Hospital, where Ms. Feldman's stepmother is being treated for breast cancer, on May 1. I told him that I had received the letter.
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.
