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UHC Terminations of Physicians in Medicare Advantage Plan

In mid-October UHC began terminating physicians in their Medicare Advantage plan. We immediately reached out to UHC when it appeared that the terminations were not isolated, but rather part of a   broad initiative. This week, UHC responded to some of our questions. We are disappointed that there was no warning of this termination initiative which appears to be a significant redesign of the UHC Medicare Advantage network, nationwide, and that information is sparse. For example, UHC would not tell us how many physicians in New Jersey were terminated or whether any specialties were immune to the termination initiative. Yet, UHC assured us that the network had been “tested and retested” for network adequacy and that there would not be a specialty access issue.

Network Adequacy: Obviously, MSNJ has no way of evaluating the impact on the network without more information. Therefore, we are asking all physicians who received termination letters, to provide us with information so that we can better evaluate network adequacy concerns. CMS has agreed to help us with that assessment.

Lack of Transparency: In addition to our network adequacy concerns, we are troubled that patients may be enrolling or re-enrolling in the UHC Medicare Advantage plan now, because seniors are in the middle of open enrollment, believing that they will be able to continue to be treated by physicians who are currently in the plan. UHC agreed to consider our complaint on lack of transparency on the 2014 network, given that seniors are enrolling now based on the current network. It is important to note that patients may change their network selection. CMS will honor the last selection made by the patient by December 7 when open enrollment ends.

Continuity of Care: We expressed our concerns about continuity of care and a disruption of established physician-patient relationships.  We urged UHC to carve out an exception for patients who wish to continue to see their current physician. UHC agreed to consider this request. We believe that patients should have the right to choose their physicians and must know their network status to make those choices.

Discussions with CMS: With a reopening of the federal government, we have contacted CMS about our network adequacy and continuity of care concerns. Our Region 2 office has been facilitating communication with the Region 9 office which is responsible for the UHC Medicare Advantage network. CMS Region 9 is charged with ensuring network adequacy and transparency for Medicare beneficiaries in their selection of a Medicare product. CMS has offered to test areas for network adequacy. Please provide us with information so that we can identify geographical and specialty areas of concern.

What to do: Last week we urged physicians who wished to stay in the Medicare Advantage network to appeal and provided suggestions for those appeals. We will continue to update our advice to members as more information becomes available to us.  Visit our web site for a list of Do’s and Don’ts, Appeal Suggestions, a template letter to inform patients of your imperiled status in the UHC Medicare Advantage Network.

Visit MSNJ’s UHC Webpage for more information.

Save the date for MSNJ’s UHC Termination Update webinar on Tuesday, October 29 at 7:00PM. Details to follow on

MSNJ’s Statement on NJ Medicaid Expansion

Governor Christie’s decision to expand Medicaid is a positive step that will create access to health insurance for many uninsured residents. Importantly, this decision will make additional investment in the program possible. This is also an opportunity to align incentives and create a robust network of physicians and other healthcare providers for the Medicaid program. Expanding an underfunded program will increase access to insurance, but will not deliver adequate access to physician services for our newly insured citizens.

The Medical Society of New Jersey supports reform of the state’s Medicaid Program. Our Medicaid Program is one of the poorest paying healthcare programs in the nation.* Conversely, practice expenses in New Jersey are among the highest in the nation. These unfortunate facts prevent many physicians and other healthcare providers from being financially able to participate in the Medicaid program. We look forward to working with our government and private sector partners to ensure access to quality healthcare for all New Jersey residents.

*Health Affairs August 2012 vol. 31 no. 8 1673-1679

Congress Must Act to Avert Medicare Fee Cuts Before January 1

The annual rite of organized medicine seeking congressional action to avert steep Medicare fee cuts before January 1 is upon us. However, this year is different. Not only is a 27% fee cut scheduled to occur because of the flawed SGR formula, but physicians will also be subject to an additional 2% fee cut under the sequestration. Next week Congress and the President will return to Washington to face the fiscal cliff, in addition to resolving the annual Medicare fee issue. In anticipation of this, MSNJ joined virtually all of organized medicine to support SGR Transition Principles in personal letters to the New Jersey delegation. We previously gained the personal support of many of our delegation. (See MSNJ e-News dated February 16, 2012). Members are asked to watch for a strategically timed grass-roots “call to action” on this issue.

Federal Government Creates Public-Private Healthcare Fraud Partnership

This week, the U.S. Attorney General and the Secretary of Health & Human Services announced the launch of a partnership between the federal and state governments, private healthcare insurance companies and other healthcare anti-fraud groups to prevent healthcare fraud. The effort is aimed to safeguard healthcare dollars.

The partnership will share information to improve detection of fraudulent healthcare billing.  “A potential long- range goal of the partnership is to use sophisticated technology and analytics on industry-wide healthcare data to predict and detect healthcare fraud schemes.” [Press Release, U.S. Dept. of HHS (July 26, 2012)] According to the Secretary of Health & Human Services, by sharing information across payers—public and private– potential fraudulent activity can be stopped:

In the past, we followed a ‘pay and chase’ model, paying claims first – then only later tracking down the ones we discovered to be fraudulent. … Since we have put this system in place, it has stopped, prevented, or identified millions in payments that should never have been made. And because the system is designed to get smarter over time, as it analyzes more data, it’s only going to be more effective in the future. [Speech of Secretary of U.S. HHS (July 26, 2012)]

The Affordable Care Act permits enhanced screening of physicians who treat Medicare and Medicaid patients and the suspension of payments to physicians engaged in suspected fraudulent activity. This public-private partnership will build on these fraud prevention tools.

The Federal Government has recovered fraudulent payments of $10.7 billion over the past three years. Read more about fraud prevention under the Affordable Care Act.

MSNJ Press Release: Affordable Care Act (ACA) Supreme Court Decision

Today’s Supreme Court decision finding the Affordable Care Act (ACA) constitutional will have a significant impact on healthcare delivery in the United States.

While the Medical Society of New Jersey (MSNJ) did not support the passage of national healthcare reform legislation, largely because it did not address the sustainability of the Medicare and Medicaid programs and tort reform, MSNJ has a long history of supporting access to both affordable healthcare and affordable healthcare insurance.

Earlier this year, MSNJ supported the creation of a Health Insurance Exchange (Exchange) in New Jersey. This could increase competition and remove barriers in the healthcare insurance market so that more uninsured New Jersey residents may purchase affordable healthcare insurance with transparent terms. We stand ready to work with the Governor and the New Jersey Legislature to establish a robust Exchange. MSNJ fully supports expanding the availability of affordable healthcare insurance to our residents.

We are pleased for our patients that key provisions of the ACA, supported by MSNJ, were upheld by the Court including:

The elimination of pre-existing conditions as a barrier to coverage;

  • The right of parents to insure their children on their existing policies up to age 26; and
  • The elimination of maximum life-time caps on benefits.

MSNJ continues to have concerns about whether New Jersey has the physician capacity to treat all patients who will become eligible for Medicaid with expanded eligibility requirements. Because New Jersey has among the lowest payment rates for Medicaid in the nation, together with the highest practice costs, there is already a shortage of physicians who treat Medicaid patients. Expansion of the insured population through the Exchange and Medicaid will worsen the physician shortage.  We will further analyze the Court’s opinion and work with the Governor and the Legislature to address the needs of our state’s neediest population.

MSNJ is a tireless advocate for a sustainable Medicare program. We have advocated for a repeal of the broken funding and payment formula. We know that the cost of caring for our seniors must be reduced and we intend to be part of the solution by providing quality, cost-effective, coordinated care. MSNJ supports physician-led integrated care models to provide cost efficient, quality care.