WakeMed and UnitedHealthcare disagree on insurance contract

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An ambulance arrives at WakeMed’s emergency room off New Bern Avenue in 2013.

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A dispute between WakeMed and one of the nation’s largest health insurers could affect insurance coverage for thousands of people in the Triangle.

WakeMed and UnitedHealthcare have until June 1 to agree a new contract. If they fail, WakeMed hospitals, outpatient clinics and medical specialists will no longer be considered “in-network” for UnitedHealthcare, meaning patients could pay more for services and have difficulty accessing them.

WakeMed primary care physicians have a separate contract with the insurer and would not be affected. WakeMed’s outpatient surgical centers would also not be affected, although the doctors and other specialists who work there would be.

The two sides describe the argument very differently. UnitedHealthcare says WakeMed insists on 20% price increasewhich would result in increased insurance premiums and disbursements for approximately 20,000 of the company’s customers.

But WakeMed says it hasn’t spoken of a rate increase in over a year and that disagreement over UnitedHealthcare coverage policies.

WakeMed’s Claim

Dr. Seth Brody, executive vice president and chief medical officer of WakeMed, says UnitedHealthcare refuses reimbursement for procedures and services at a rate at least five times higher than other major insurers such as Aetna, Blue Cross and Blue Shield, Cigna and Humana. This level of questioning not only hurts WakeMed, but also patients who end up with unreimbursed expenses, Brody said.

“We find that medical necessity is determined by the relationship between our physicians — all of our providers, our care team — with the patient and their family, and often at the bedside,” Brody said. “No one knows the need for medical care better than these people. And then what happens is there are days of determination, weeks later, that say, “No, that wasn’t necessary care.”

What WakeMed expects from the new contract with UnitedHealthcare, Brody said, is language that spells out the company’s reimbursement policies and helps bring reimbursement closer to other companies.

“The process of saying was it medically necessary or not, we do that with all the other payors. And they seem to be coming to the conclusion that we are providing medically necessary care at a much higher rate than United,” he said. “That means there is something wrong here.”

What UnitedHealthcare says

UnitedHealthcare counters that some of WakeMed’s proposed changes would “limit consumer freedom and choice.”

“Specifically, WakeMed’s request would prevent UnitedHealthcare from providing members with quality and cost information that could influence their decision to seek care from a provider other than WakeMed,” the company says on its website.

UnitedHealthcare says WakeMed has been unwilling to negotiate since it informed the company last fall that it wanted to terminate the contract on June 1. He claims to have made two complete tariff proposals, in December and March, and received no counter-proposal from WakeMed. .

“We have made significant compromises and offered meaningful rate increases that would pay WakeMed competitive rates,” the company said in a written statement Friday. “But the health system has refused to engage in meaningful negotiations and has never countered the multiple proposals we have provided since December.”

Brody says WakeMed hasn’t talked about price increases because he wants to negotiate a new reimbursement policy first. And despite what the company says, the two sides are talking to each other, Brody said.

“There were discussions that took place this week. There is more planned,” he said. “We are motivated to reach an agreement because we want to protect our patients and their access to quality care. I hope they are also motivated for their reasons to reach an agreement.

UnitedHealthcare provides insurance to approximately 12% of WakeMed patients. The health system, which has hospitals and clinics throughout Wake County and Clayton, notified patients of the dispute in a letter this week.

This story was originally published May 6, 2022 5:51 p.m.

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Richard Stradling covers transport for The News & Observer. Planes, trains and automobiles, as well as ferries, bicycles, scooters and simply on foot. Also, hospitals during the coronavirus outbreak. He was a journalist or editor for 34 years, the last 22 of them at the N&O. 919-829-4739, [email protected]

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