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Federal Regulators Say Networks Are ‘Adequate’

by Christine Stuart | Dec 12, 2013 4:32pm
(1) Comment | Commenting has expired
Posted to: Courts, Health Care, Legal

CTNJ file photo Back on Nov. 5 before a federal judge agreed with two medical associations that UnitedHealthcare should stop dropping doctors from its Medicaid Advantage network, Attorney General George Jepsen asked federal regulators to “aggressively scrutinize” the decision.

Federal regulators at the Centers for Medicare and Medicaid Services looked at the decision and concluded the insurance company’s networks were adequate.

“Our review of the anticipated provider network in Connecticut has not found any issues with network adequacy,” Douglas Edwards, associate regional administrator at CMS, wrote in the letter.

The review of the networks that CMS conducted were based on time, distance, and number standards. It did not take into account “the special needs of the disabled, elderly, low income, without personal transportation, and non-English speaking members,” Edwards wrote.

Jepsen called the decision disappointing.

“I have repeatedly pressed CMS to aggressively scrutinize UHC’s network to determine its adequacy, but have seen no evidence that it has done so,” he said in a statement.

“Remarkably, CMS concedes that it failed to consider the special needs of the disabled, elderly, low income, those without personal transportation and non-English speaking patients. In other words, CMS has approved UHC’s network without considering the needs of those who most need protection,” Jepsen said. “Nor has CMS independently verified that existing patients are being offered suitable alternatives for their terminated doctors — that is, substitute doctors with the appropriate expertise and capacity to accept new patients.”

Last week, a federal judge ruled in favor of the two medical associations that took UnitedHealthcare to court. The judge said the insurer needs to stop dropping doctors from its network and to reinstate the ones it planned to drop.

U.S. District Court Judge Stefan Underhill wrote that while UnitedHealthcare argued it was terminating the physicians without cause based on their contract, the company failed to “provide written notice of the ‘reasons for the action, including, if relevant, the standards and profiling data used to evaluate the physician and the number and mix of physicians needed by the MA organization.’ That did not occur here, in apparent breach of both Medicare regulations and the Physician Contract provisions regarding termination.”

UnitedHealthcare is appealing the decision to the 2nd Circuit Court.

Earlier this week UnitedHealthcare told the Hartford Courant it plans to proceed with network cuts to doctors who aren’t members of the associations.

The insurance company has declined to say how many physicians it intends to terminate from its network. According to the two medical associations, the insurance company was planning to drop 2,250 physicians from its network.

Federal regulators have also decided not to release termination numbers.

“We are not releasing specific numbers regarding provider terminations at this time, but as noted above, we are investigating all complaints relating to the network changes,” Edwards wrote in his letter to Jepsen.

Meanwhile, medical associations across the country are filing court briefs in support of the Fairfield County Medical Association and Hartford County Medical Association’s complaint against UnitedHealthcare.

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posted by: lkulmann | December 15, 2013  9:07am

“Remarkably, CMS concedes that it failed to consider the special needs of the disabled, elderly, low income, those without personal transportation and non-English speaking patients. In other words, CMS has approved UHC’s network without considering the needs of those who most need protection,” Jepsen said. “Nor has CMS independently verified that existing patients are being offered suitable alternatives for their terminated doctors — that is, substitute doctors with the appropriate expertise and capacity to accept new patients.”

CT Medicaid programs don’t do this for their own State ‘at-risk’ residents either. All I got for my disabled son was a Pharmacist telling me to find a new MD. We won’t pay for this MD prescriptions anymore. So, in summary, we fight for UHC at-risk clients and we neglect CT Medicaid at-risk clients. Jepsen represents them. Who advocates and represents our Medicaid clients. Do we have a Healthcare Advocate that works for the defenseless, compromised clients?