United Healthcare out of network at WakeMed after contract expires
“Twenty-four hours in advance, I have to cancel appointments so I don’t get charged network fees. And then I hold appointments in case a deal is struck,” said Lee Lenahan, a WakeMed Patient who has UnitedHealthcare.
Lenahan and her husband are both retired and have health insurance; he suffers from long-term dementia and diabetes.
“I’m now a full-time caregiver for my husband. It’s my choice,” Lenahan explained.
She noted that this limits her ability to find a job that might offer a different health care plan. This has led to concerns that potential future appointments and visits will not be covered if they stay with the same providers.
WakeMed and United Healthcare blamed each other for letting the contract expire.
In a statement to ABC 11, United Healthcare wrote:
“Based on WakeMed’s actions over the past several months, we can only assume that the healthcare system always intended to disrupt access to care for the people of North Carolina. We have made many attempts to find compromises and find solutions through good faith negotiations Unfortunately, WakeMed chose to cancel our contract, declined our offer to extend our current agreement and never countered multiple pricing proposals we have provided since December. We will remain at the negotiating table as long as it takes to renew our relationship. We urge WakeMed to join us there and work towards a solution that is in everyone’s best interest.”
United Healthcare said all but five hospitals in the state participate in their Medicaid network, three of which are WakeMed facilities. They alleged that WakeMed requested a 20% rate hike in the first year of the contract.
“There hasn’t been a rate increase over that period. A lot has happened in health care and around inflation and other costs. And you combine that with denials of care that we actually provide – it’s not really a tenable scenario to continue with UnitedHealthcare in this regard,” said Dr. Seth Brody, chief medical officer and executive vice president of WakeMed.
Brody added that their primary focus was not on rates, but on issues with the claims approval process.
“They’re denying, it’s care already provided, they’re denying reimbursement for medically necessary care, physician and patient determined care – they’re denying five times or more than all the other payers. So these denials are really important, that makes United haven’t really evolved significantly in defining its policies and procedures which it uses to define how it denies these allegations,” said Dr Seth Brody, Chief Executive Medical Officer and Vice President. executive of WakeMed.
United Healthcare reported that over the past 12 months, they approved nearly 90% of WakeMed’s claims. Of the rejected claims, they said most were due to administrative errors on WakeMed’s part. While Brody acknowledged that human errors do happen, that doesn’t account for the big gap with other insurers.
Despite the standoff, Brody said some services would not be affected.
“There are continuity of care clauses that can be fulfilled so that our patients can call United Healthcare and see if they are eligible for continuity of care. So if you have ongoing treatment, that can be covered. All emergency services are covered at WakeMed under the No Surprises Act the government passed in January. UnitedHealthcare must cover you for emergency services. There are scenarios where continuity (of care) also applies to the pregnancy. So if you’re in the second or third trimester, you can continue to transmit and have services at WakeMed,” Brody said.
The most recent contract was for seven years, which is longer than WakeMed’s agreements with other insurance companies. WakeMed encouraged patients to contact questions or cost estimates directly, either by email at [email protected] or by phone at 919-350-7808, option 9.
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