Healthcare providers across the State of Michigan are continuing to experience terminations and non-renewals from UnitedHealthcare’s Medicaid, MIChild, and Medicare Advantage plans. As previously discussed on this blog, the network exclusions are part of UnitedHealthcare’s nationwide move to narrow networks. Narrow networks limit the amount of physicians available to plan subscribers, which some argue allow plans to better control costs and thus provide premiums that are competitive in the new insurance marketplaces. The real issue, however, is that the manner in which UnitedHealthcare is effectuating its narrow network eliminates patient choice by forcing patient’s to stay with UnitedHealthcare until their anniversary date, despite the fact that they enrolled in UnitedHealthcare with the intent to be treated by their long-term primary care physicians.
In Michigan, providers receiving Terminations Without Cause and Nonrenewals from UnitedHealthcare are granted a limited appeal right via their Participation Agreements. The appeal process, however, is “limited to a review by a UnitedHealthcare panel to determine whether UnitedHealthcare acted in accordance with the provisions of your Participation Agreement.” Accordingly, although an appeal must be filed in order to protect the provider’s appeal rights, the appeal itself may not be effective and providers must look to alternate methods in order to protect physician and patient rights.
Our firm represents multiple primary care physicians facing without cause exclusions from UnitedHealthcare. As the appeal right provided by UnitedHealthcare is insufficient, our firm has contacted the Michigan Department of Community Health (DCH) as well as representative from the State’s Attorney General office in order protect our clients’ and their patients’ rights and achieve a solution that either provides a meaningful appeal process or reinstates patients’ rights to choice of provider.
We maintain that UnitedHealthcare’s contractual obligations extend further than the providers’ Participation Agreement. For example, in order to operate Michigan’s Medicaid managed care program, UnitedHealthcare entered into a State Plan Contract (“Contract”) with the State of Michigan that dictates UnitedHealthcare’s contractual and legal obligations in operating their Medicaid managed care and MIChild plans. The Contract, as well as all applicable Medicaid laws, regulations and policies, serve to define the legal relationship between the State of Michigan, UnitedHealthcare, Medicaid providers, and Medicaid enrollees. The State Plan Contract includes provisions regarding network adequacy, network changes, and the enrollee’s right to choose their primary care physicians. Specifically, the Contract includes language stating “[Plans] must make all efforts to honor the enrollee’s choice of Primary Care Physician” and that “if [the Plan] cannot honor the enrollee’s choice of Primary Care Physician, [the Plan] must allow the enrollee to either make a choice of an alternative Primary Care Physician or to disenroll.” In addition to the Contract, we are examining provider and patient rights under Michigan’s Medicaid State Plan, which includes, for example, Section 4.10 covering enrollees’ rights to free choice of provider.
Our position is that UnitedHealthcare must comply with these authorities when effectuating their narrow network, and cannot extinguish the enrollees’ right to choose their primary care physicians. We are challenging UnitedHealthcare’s actions of inducing patients to sign-up for a specific plan in order to see their primary care physicians, and then excluding the physicians in a way that prohibits the enrollees from being treated by their long-term primary care providers. The patients must either be able to continue to see their primary care physicians until their renewal date or, alternatively, be given an opportunity to disenroll and choose another plan that their physician participates in.
Please let our firm know if you have received a Termination or Nonrenewal notice from UnitedHealthcare and seek assistance in protecting your medical practice and its patients. Wachler & Associates has represented healthcare providers across the country for over 25 years, including countless successful challenges to insurance company actions impacting providers. Our experience in these matters, as well as the fact that we are currently representing providers challenging UnitedHealthcare’s unlawful exclusions, will allow us to effectively and efficiently fight to protect your providers’ and patients’ rights.
If you would like to speak to one of our experienced health care attorneys, please contact us via our website or call our firm at 248-544-0888.