What Physicians Should Do When Cut from an Insurer's Network

Very few doctors do what subspecialist ophthalmologist Steven Thornquist does, at least near Trumbull, Conn.

So when Thornquist, one of a handful within a 20-mile radius who specializes in pediatrics and neurologic and diabetic eye problems, was dropped from UnitedHealthcare's Medicare Advantage plan last fall when the payer announced it was cutting an unspecified number of physicians, he feared for his patients - and his physician colleagues.

"There are only four people in Fairfield County [Conn.] who do what I do, and three of them aren't in the UnitedHealthcare plan anymore," Thornquist told Physicians Practice.

But while only about 40 of Thornquist's patients relied on UnitedHealthcare's Medicare Advantage plan, other physicians with hundreds of UnitedHealthcare Medicare Advantage patients are seeing a far bigger impact to their bottom line.

"It was not the majority of my practice, as it was for some of my colleagues," said Thornquist. "[For] one of my colleagues, it was 1,000 patients. For a primary-care doc, it can be a third of your practice."

In December, a federal judge in Connecticut temporarily blocked UnitedHealthcare from dropping an estimated 2,200 physicians from its Medicare Advantage plan in that state. Currently, an appeal of the temporary injunction by UHC is pending in the 2^nd circuit court of appeals. But the victory, it seems, may be temporary.

In the months since healthcare exchanges resulting from the Affordable Care Act rolled out, the issue of physicians being dropped from networks seems to have become a national problem.

UnitedHealthcare told Physicians Practice via e-mail that there is "no link" between the timing of the healthcare exchanges entering the marketplace and its decision to truncate its network of Medicare Advantage physicians.

When asked why it dropped so many healthcare providers from its Medicare Advantage plan, a company spokeswoman told Physicians Practice in an e-mail message that, "in an era of Medicare funding cuts, these changes are necessary to respond to quality improvement imperatives and will improve our ability to collaborate with physicians to encourage better health outcomes for our members and help keep health insurance affordable … Ultimately, we believe that collaborating with a smaller, more focused network of physicians will help us offer higher quality and more affordable healthcare coverage for our members, resulting in better access to preventive care for those with complex healthcare needs."

And while UnitedHealthcare's newsworthy network cuts have made the biggest headlines, physician leaders fear that other insurers may follow suit.

"If this is what we're going to be seeing in healthcare, it's a big concern," Michael Saffir, president of the Connecticut State Medical Society and a board-certified physiatrist who practices with the Orthopedic Specialty Group in Fairfield, told Physicians Practice. "The first reaction of my group [to the UnitedHealthcare news] was that we would switch payers and let our patients know. So let's say we can survive that. Then the question is, 'Will other payers do this?'"

So what is a physician to do if they're cut from a health plan? Here are three steps:

1. Sound the alarm. One of the first things Thornquist did was to contact his state medical society, which advised him to file an appeal. "Find out what your rights are," said Thornquist. "Look at what's in your contract and definitely appeal … If everyone appeals it and [the insurer] doesn't get to the appeal in the appropriate amount of time, they're in breach of contract."

2. Let patients know ASAP. Because Thornquist had a small portion of UnitedHealthcare Medicare Advantage patients, he spoke to them personally, and let them know their options: find another healthcare provider, switch carriers, or pay him out of pocket. For physicians with a larger portion of patients, informing them by secure e-mail or letter might be a more feasible option. Just be aware that insurers usually have language in their contracts that prevents physicians from saying anything defamatory against them to patients. "You can't demean or defame," says Thornquist. "I always advise them is to make sure they know what options are but you can't [tell them] to boycott UnitedHealthcare."

3. Consider alternatives. Saffir noted that while there are no guarantees, physicians could explore the option of trying to diversify payer mix, so if a plan is cut, the effect is less severe. Thornquist said he knows of physicians who have responded to being dropped from UnitedHealthcare's Medicare Advantage plans by dropping all of the payer's plans (the carrier has an all-products clause in Connecticut). The bottom line: By taking some kind of decisive action, you're taking a stand that could have a broader influence on court proceedings, as it may have in Connecticut. "Don't be cowed by this," said Thornquist. "Docs shouldn't take this lying down."