Out of Network? How Did That Happen?
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What Do You Mean Out of Network?
We wrote a that Scripps medical in San Diego was no longer accepting Medicare Advantage plans and that affected over 30,000 seniors. Now in my part of the world, Regence Blue Cross can’t seem to come to terms with Legacy Health and many of my acquaintances are losing access to their doctors. Some of these people have important surgeries scheduled and all of a sudden - no access.
One of the most unfair aspects of medical insurance, in a system that often seems designed for frustration, is this: Patients can change insurance only during end-of-year enrollment periods or at the time of “qualifying life events,” such as a divorce or job change. But insurers’ contracts with doctors, hospitals and pharmaceutical companies (or their arbiters, so-called pharmacy benefit managers) can change abruptly at any time.
That is particularly galling for patients because, whether obtaining insurance through an employer or buying it on the marketplace, they generally choose a policy based on whether it covers their desired doctors and hospital or an expensive drug they need. Turns out that particular coverage could evaporate at any time during the policy term.
Consumers are put at risk, according to a recent report by the Robert Wood Johnson Foundation, in the escalating warfare over pricing between big, consolidated hospital systems and ever-bigger insurers in a cutthroat market. Such contract disputes are increasing rapidly — the Becker’s Hospital Review website cites 21 insurer-provider standoffs in the third quarter of 2023, a 91% increase over the same period the year before.
For example, last September, the physicians at Baptist Health in Kentucky abruptly cut ties with patients enrolled in Humana’s Medicare Advantage plans, and physicians at Tennessee’s Vanderbilt Health broke off contracting with a number of Humana Plans in April — in both cases sending patients scrambling to find new in-network doctors affiliated with other hospital systems. And experts predict more contract terminationsin a merciless market.
State and federal regulators have the authority to regulate insurers’ networks and could end the practice, but there hasn’t been federal regulation about continuity of coverage, particularly how to define it.
Many insurers say they will continue paying for a period after a contract ends — often 60 to 90 days — or to complete an “episode of care,” for a pregnancy, in particular. But with, say, cancer, would that mean one round of chemotherapy or the full course of treatment, which could last for many years? Is it continuity of coverage if a patient must change oncologists midstream or if a patient has to leave an effective therapist?
All of this goes away with universal healthcare but until then let’s let our lawmakers know that they can help.
Our State and Federal representatives can help by removing weasel words from our insurance policy documents that allow the insurance company to alter the terms of the agreement during the year the policy is in force.
ACTION
There is something that lawmakers can do at the state and federal level. They can demand that the policy sold to the consumer include the networks that were in place at the time of the sale to allow for continuity of coverage at least for the premium year. Their contact info is in the resources section below or use the two Resistbot actions below to send the email below to ourMembers of Congress and Senators and again to our State representatives and Governor.
FEDERAL -Text to 50409 SIGN PEIGEB (Resistbot)
STATE-Text to 50409 SIGN PVTKNT (Resistbot)
“I am your constituent and I am shocked to learn that my health insurance company can change my network in mid year. I will lose access to my doctor. If you haven’t seen it, yet this is going on all over the country. People are losing access to their doctor’s mid year. Many just as surgeries are ready to get underway. What about people in treatment for cancer? Then what do we do?
You can change this and I want you to do it. I want you to implement rule that every commercial insurance plan has to pay for providers as in-network for the policy year in which I paid for the plan as long as that provider is still in business. This will prevent tremendous disruption to our healthcare. Thank you.”
RESOURCES
Healthcare Advocacy (Us)
Website
Our Newsletter resources including reproductive healthcare
Healthcare Advocacy Reading List
Find My Elected Officials
Contact the White House https://www.whitehouse.gov/contact/
Contact State and Federal Representatives
By phone: (202) 224-3121
By email: democracy.io
Important Healthcare Resources
League of Women Voters Healthcare Reform Toolkit
Organizations to Contact
National Nurses United Medicare4All
Physicians for a National Health Program
One Payer States
Healthcare Now
Reproductive Health
NARAL - Pro Choice America
Charley. chatbot abortion resource - make sure to use a secure incognito browser if you live in a state that has banned abortion
Planned Parenthood
Miscarriage and Abortion Hotline has references about where to procure abortion medications. They also assist women in the process of self managed abortion or miscarriage by phone or text and will respond in an hour. Details and hours of operation at their website.
United State of Women Reproductive health page (bottom of the page) has important resources such as medical support, access to Telehealth, prescriptions by mail, and legal support references.
Practice careful communications - The Digital Defense Fund has a number of tips to keep texts, calls, and internet use private. Here is their site.
If you need financial help with an abortion try abortionfunds.org
Claims Denials and Appeals & What to Do
Appeal a Healthcare Decision
Appeal/Negotiate a Hospital Bill
Disinformation Management
Cybersecurity Infrastructure Security Agency
Save Democracy
Chop Wood, Carry Water by Jessica Cravens
RESISTBOT
Link to the RESISTBOT site to learn more
Link to Chop Wood, Carry Water RESISTBOT write up
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This is why I have original Medicare. I’ve read that if Trump is elected, original Medicare will cease to exist. Gotta keep those health insurance companies rolling in our $$$$!
Thanks for spotlighting "out of network". A few years ago, I penned a post, "The Surprising Conservative Case for Universal Healthcare" (https://medium.com/@idember/universal-healthcare-the-surprising-conservative-case-656d23617a3a). It started off with this point:
"Private health insurers take away our free choice of doctors by imposing artificial networks. M4A guarantees free markets. At last we’ll choose doctors in a true free-enterprise system with real competition."
Free enterprise in healthcare? A debatable notion. But to conservatives it's a core tenet. As your examples demonstrate, artificial networks poison a healthy free market. This idea can help sell universal care to conservative audiences -- say, Eisenhower Republicans, who at long last are again gaining a bit of traction.