As contract negotiations between the insurance company and the hospital broke down, the patient was trapped outside the network


In September, when Shirley Azopadi went to Kenneston Hospital in Wales due to abdominal pain, she was not worried about her insurance.

The doctor said that she suffered from appendicitis. But she also tested positive for COVID-19 at the Marietta, Georgia hospital. The doctor decided not to perform surgery and treated her with antibiotics and painkillers. Azzopardi, 47, went home after staying in the hospital for a few days and felt much better.

But in October, appendix pain reappeared. Her husband took her to the same hospital and the operation was successful. However, this time, her insurance ran into trouble.

Azzopardi has UnitedHealthcare insurance. As of October 3, after the two parties did not agree on a new contract, Wellstar Health System no longer belongs to the network of this large insurance company.

Wellstar controls the area of ??Cobb County where Azzopardi and her husband live. She has applied for a “continuous care” exemption from UnitedHealthcare, which will expand her previous network coverage for the treatment of persistent illnesses during hospital visits and operations in October. If unsuccessful, she may owe thousands of dollars. “I don’t know where it is,” Azzopardi said.

On a larger level, the severance of contracts between the hospital system and health insurance companies reflects the growing tensions across the country this year. In the past, even if contract negotiations became openly opposed, they were usually resolved before the termination deadline.

Now, healthcare consultants and industry officials say that more and more contracts are terminated without an agreement. Even if they are finally resolved, these terminations will leave tens of thousands of patients in trouble, choosing between much higher out-of-pocket costs or leaving trusted doctors and hospitals.

The situation between Wellstar and UnitedHealthcare-and the greater dispute in the Atlanta metro area involving Anthem Blue Cross and Blue Shield-is very tricky. During the open admissions season, many employers have already chosen their insurance products, and many consumers Must choose their health plan.

“We are seeing more and more insurance companies terminating contracts without reaching an agreement. This is a national and local trend,” said Beth Spoto, a health care consultant at Spoto & Associates in Georgia. She said that from the perspective of insurance companies, reducing the payment rate of medical service providers is a tough strategy.

“The health system is getting bigger and bigger, so you have to deal with hundreds of millions of dollars,” she said. “The battle has become very difficult.”

Recent contract terminations involving major insurance companies include UnitedHealthcare and Montefiore Health System in New York, and Anthem and Dignity Health in California. Every conflict was eventually resolved, although Montefiore took several months to resolve.

The hospital reports that negotiations with health insurance companies have become more tense, Molly Smith said American Hospital Association vice president. She said that contract negotiations are usually not carried out by the insurance company’s local executives, which may allow for more cooperation, but are guided by the company’s headquarters.

In the Atlanta area alone, other out-of-network situations involving insurance giants UnitedHealthcare and Anthem have occurred in the past few years. The Gwinnett County facility at Northside Hospital interrupted UnitedHealthcare members’ networks for five months, while the Northeast Georgia Health System in Gainesville eliminated Anthem’s lineup for three months.

In the recent dispute, Wellstar stated that it expects UHC to pay similar to compensation received from other insurance companies. UnitedHealthcare, headquartered in Minnesota, countered that Wellstar hopes for an “amazing” rate hike, and the insurance company said it would raise interest rates by 37% within three years.

“Both said the other was just for money,” Azopaldi said. She said this deadlock “is cruel to patients who have done nothing wrong.”

The dilemma of open registration made Emilie Cousineau of Smyrna, Georgia wonder whether to stay in UnitedHealthcare or switch to Anthem, which she said will make her spend more in the upcoming benefit year of the employer’s plan.

Cousineau recently cancelled the Wellstar Well inspection appointment because it was suddenly disconnected from the internet. “Now, this is an inconvenience.” But her doctor and her child’s pediatrician are both Dr. Wellstar. “I am very picky about my health care,” she said.

The consultant said that the uncertainty of COVID and rising hospital labor costs are exacerbating this disruption.

As people avoid healthcare due to fear of COVID, health insurance companies recorded sky-high profits last year. This year, profits have declined, but they are still healthy. For hospitals, the pandemic has had mixed results.Some A wealthier and larger health system has accumulated huge surplusesWith the help of the COVID Relief Fund, many safety nets and rural hospitals are striving to achieve a balance of payments.

Cole Manbeck, a spokesperson for UnitedHealthcare, said that the affordability of healthcare is of the utmost importance to consumers and employers. He said that they want insurance companies to help control costs, which requires fair and competitive agreements with hospitals and doctors in their network.

The insurance company also pointed out that the healthcare system has increased their bargaining power by acquiring more hospitals and doctors’ clinics.Dave Smith of a healthcare consulting firm said that difficult negotiations extended to doctors’ group contracts Carney Street ManagementHe said that insurance companies “are working hard to reduce the cost of healthcare and do so with the support of doctors and hospitals.”

The factors leading to competition are delays in payments involving insurance companies Anthem and UnitedHealthcare.Hospitals are responding to the surge Retroactive claim denial Smith of the American Heart Association said UnitedHealthcare provides emergency department care.

KHN also recently reported that Anthem Blue Cross defaults on billions of dollars in payments According to hospital officials in multiple states, money owed to hospitals and doctors due to onerous new reimbursement rules, computer problems, and improper handling of claims.

Tom Mee, CEO Northland Healthcare In New Hampshire, Anthem’s pending claims owed to his system increased by $250,000 in a quarter to $1 million.

Anthem, based in Indianapolis, said that the contract differences had nothing to do with the claims. Both it and UnitedHealthcare pointed out that most contracts are renewed without public attention.

At the same time, employers don’t like these network outages, saying Ash Shehata, KPMG’s healthcare consultant. However, he added that employers also do not want to subsidize interest rate hikes.

“When the situation is good, everyone is doing well, and usually you don’t see these negotiation issues,” he said. “As long as the environment remains unpredictable, we will see some unpredictable negotiations.”

Compared with insurance companies, the termination of the contract is more harmful to the hospital, Nathan Kaufman said Kaufman Strategic AdvisorFor example, UnitedHealthcare and Anthem, which do business in multiple states, “may be hit in one state,” he said, because they are diversified and insurance companies will still receive members after the contract with the hospital expires. Of premiums.

“On the first day, the hospital started to feel more and more financially pressured,” Kaufman said. “They have experienced this kind of financial shock.”

The Atlanta market is facing another such contract interruption. Anthem has reminded consumers that Northside Hospital and its facilities may not be part of its network on January 1. Although the tug of war between Wellstar and UnitedHealthcare involves an estimated 80,000 consumers, the Northside contract may affect four to five times as many consumers, according to Northside officials.

“Anthem’s time is very detrimental to our patients,” said Northside spokesperson Lee Echols. “It’s hard to understand. We are still in a pandemic, and this is the open registration period for health care policyholders. Many people are returning to their doctors and hospitals for deferred treatment, and Anthem’s threat makes this process very meaningful. challenge.”

But Anthem spokesperson Christina Gaines said the company is trying to control health care costs, and Northside is one of the most expensive systems in Georgia.

This matchup caused concerns and confusion among consumers such as Carol Rand of Sandy Springs, Georgia.

She has been a member of Anthem for many years and has used nearby Northside facilities and doctors. She is now buying other plans to see if they will include Northside in their network. An insurance plan has her doctor, but not her son’s doctor.

“It’s so frustrating,” Rand said. “This is a big deal in this area.”



Source link