A practice in Connecticut details the impact of removal from a payer's network
About a year ago, James R. Pinke, M.D., an ophthalmologist in solo practice in Connecticut, received letters from a trio of insurance carriers outlining their plans to create special networks of “five-star” physicians for 2014. Then came a letter in late October with unexpected contents: Pinke would be removed as an in-network provider for UnitedHealthcare’s 2014 Medicare Advantage (MA) network, effective February 1. He was not alone: more than 2,000 other Connecticut physicians also were being ousted.
Overnight, everything changed for Pinke Eye Center in Shelton, where he has practiced for 31 years. When he started out, about 500 of his active patients were covered by United’s MA plan. Medicare comprises fully 87% of Pinke’s practice--and United’s MA plan is second only to traditional fee-for-service Medicare plus supplemental insurance for his patients.
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“Effectively, we would have had to shut our doors. That’s how many United Medicare Advantage patients we had,” says Tina Pinke, the practice administrator who is also the ophthalmologist’s wife.
According to Tina Pinke, the practice received no explanation from United concerning her husband’s initial exclusion from its 2014 MA network. “It’s very threatening to any practice to be removed from a very large Medicare Advantage network with no feedback,” she says, noting that her husband has performed more than 30,000 cataract procedures “with no problems, no ‘black letters,’ nothing.”
United spokesperson Betsy Chin says the company’s decisions regarding network inclusion “are influenced by multiple factors, but they are locally driven and based on a combination of geography, quality and efficiency. When making decisions about our network, we focus on ensuring that our members will have ready access to care and also consider providers’ relative performance on industry quality metrics and their ability to deliver high-quality care for the most members in the most cost-efficient manner.”
Initially, Pinke stayed on United’s 2014 online provider directory. Brokers knew of insurers’ narrowing networks, but they had been given directories and still saw Pinke among listed network physicians. So did patients.
“There was mass confusion about who was in and who was out,” Tina Pinke says, explaining her husband’s name was on and off the list for a while. After two weeks, a United provider services representative returned the practice’s phone calls and confirmed that Pinke would be removed from the MA network.
Subsequently, the practice tried phoning 500 patients to alert them that Pinke wouldn’t be in-network, explaining that meant he couldn’t take United’s MA patients – most of them elderly and coming to him for 30 years with active eye diseases such as glaucoma – after February 1, 2014.
The town’s only other ophthalmologist also had been removed from United’s 2014 MA network, leaving no ophthalmologists in-network at the local hospital, Tina Pinke recalls. Two local medical societies, along with Pinke and several other physicians, became vocal about the matter and hundreds of people attended a town hall meeting. On December 4, days before the MA open enrollment period ended, Pinke received a letter from United saying he was back in its 2014 MA network.
“None of our patients were notified, though,” Tina Pinke says. “It caused a lot of animosity-patients blaming us, thinking Dr. Pinke did something wrong. It puts you totally on the defensive.” She says it caused a “tremendous amount of disruption” to the practice, lengthening office visits because of explanations to patients at check-in and again by the ophthalmologist during exams.
United’s initial letter to Pinke last fall “said you could appeal, and we immediately sent a certified letter, but we never received acknowledgment of the appeal,” and United’s followup letter in December didn’t mention it, Tina Pinke says. “It just said, ‘After further review of our network, we decided to include you.’” She isn’t sure whether the Fairfield and Hartford county medical societies’ legal involvement on behalf of members played a role.
In the end, she estimates that Pinke’s practice lost about two dozen Medicare patients, “because they thought they had to go find another provider, so they did.”
United’s Chin says the insurer is approaching its 2015 MA network formation differently in Connecticut and elsewhere. “We have made several enhancements to our process based on our experience and the feedback we received from providers, members and other stakeholders,” she says. “Specifically, we have made improvements to our provider and member communications, and have enhanced our notification process so that member notices will be mailed as soon as possible following provider notices.”
United also will provide accurate information about a physician’s network status for 2015, Chin says. “For providers who will no longer participate in the network, we will reflect a termination date in our online directories at least 30 days prior to the change taking effect,” she says. “and the directory will display that they are not accepting new [United MA] members as patients.”
The Pinke Eye Center also is handling matters differently this year. “In October, we will hand out letters to anybody coming into our practice to be aware of open enrollment and make sure their doctors are in their network,” says Tina Pinke. “We got business cards from local insurance brokers to help patients find resources [if they request assistance] because we can’t be giving people insurance advice.”
Tina Pinke worries that she could learn the practice is being excluded from a network at any time, “and I have no way to prevent it or to help the patients understand why it would happen.”
“I really am holding my breath to see what’s going to happen in 2015...Believe me we’re struggling. It’s a very scary time right now for us and for our patients,” she says. “They’re narrowing the networks, increasing out-of-pockets. It’s a nightmare and tough, especially in a solo practice, to keep your head above water.”