to their networks. Particularly in an era of Medicare funding cuts, these changes are necessary to respond to quality im- provement imperatives and will improve United’s ability to collaborate with phy- sicians to encourage better health out- comes for its members and help keep health insurance affordable.” Ms. Pappas didn’t say how many
Texas physicians United has terminated from Medicare Advantage plans but did say the company expects the network will be between 85 percent and 90 per- cent of its current size nationally by the end of 2014.
“Changes in individual markets will
differ depending on the local physician community, the health care needs of our members, and our responsibility to provide appropriate access to physicians and specialists,” she wrote. Ms. Pappas adds that United’s “health plan networks will continue to expand and contract depending on numerous factors in the marketplace. We evaluate our provider networks for all of our lines of business on an ongoing basis.”
Protecting patients, physicians Edith Kallas, a New York attorney who focuses on health care and insurance litigation, prepared the amicus briefs for TMA and the other state societies. “At the appropriate time, TMA could seek to intervene and become a party in the action ... in Connecticut,” Ms. Kallas said.
Should TMA be able to join the case and should it result in a favorable out- come, Texas physicians could contest their network terminations via arbitra- tion with United. In their brief, TMA and the other state medical societies told the appeals court the Connecticut lawsuit serves the interests of their members because “United’s improper termination of phy- sicians from the [Medicare Advantage] network would negatively affect other physicians, who would have to bear the burden of serving Medicare patients (at low Medicare rates) who would start coming to them in the absence of their regular doctors.”
The brief explains that physicians and practices remaining in network would
face undue strain “and potentially com- promise those providers’ doctor-patient relationships with their other patients. In addition, under United’s unilateral amendment justification, all physicians in United’s networks remain subject to termination at any time and for any of United’s products. Thus, in challenging United’s use of this method of termina- tion, the associations are protecting all of their members’ interests.” Among physicians’ concerns regard-
ing United’s actions is the effect the de- cision will have on continuity of patient care. Over the course of her 27-year medical career, Dr. Torres has developed a knowledgeable and reliable referral base of specialists. “Continuity of care is huge, especially if patients have complicated medical is- sues or are in the middle of an active treatment plan. Currently, if patients ask me which specialists they can see on their United Medicare Advantage plan, I have no way of knowing who is still in the network unless I call each office,” Dr. Torres said.
Connecticut’s county medical associa-
tions aren’t the only organizations that have resorted to suing United. In late December, the Medical Society of the State of New York filed a federal lawsuit to stop the insurer from removing 2,000 of its member physicians from its Medi- care plans effective Jan. 1. The medical society’s complaint al- leges United sought to offset “reduced federal payments under the Affordable
Care Act” when it terminated physicians’ Medicare contracts. At press time, an Eastern District court judge hadn’t yet ruled on the injunction. Judge Pamela Chen denied United’s request for a tem- porary restraining order on Dec. 23.
Physician appeals termination In the termination letter United sent Dr. Lin, the company cited a provision of the physician’s contract with the carrier as the basis for amending his participa- tion status in the Medicare Advantage network. The provision states: “We can amend
this agreement or any of the appendices on 90 days’ written or electronic notice by sending you a copy of the amend- ment. Your signature is not required to make the amendment effective.” United offers Texas physicians the opportunity to appeal their termination from the Medicare Advantage network, and Dr. Lin opted to do so. “I called my local United representa-
tive for information on required docu- mentation for the appeal process. I was told simply to submit pertinent informa- tion. There were no requirements other than responding within 30 days of re- ceiving the letter,” Dr. Lin said. TMA has a white paper that will help physicians appeal network terminations. (See “Help With Appeals From TMA,” below.) Before his appeal hearing, Dr. Lin sent United 100 pages of documentation that he says demonstrate his ability to
Help with appeals from TMA
TMA’s white paper “Physician Steps in Termination of Network Participation” helps physicians appeal insurance network ter- minations. It is available from the TMA Knowledge Center by calling (800) 880-7955 or emailing
knowledge@texmed.org. The information addresses physicians’ rights when faced with termination from insurance company networks.
March 2014 TEXAS MEDICINE 41
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