After spending time reviewing dozens of provider and payer statements over the past several months, one pattern has become clear to me: most contract disputes are about reimbursement levels — that is, how much the health carrier pays the provider for each service.
But not all of them. Some of the most significant disputes have centered on the terms of the contract itself, rather than the reimbursement rates.
A good example of this is the high-profile dispute between UnitedHealthcare and Johns Hopkins Medicine, which ended in Johns Hopkins going out-of-network on August 25, 2025. Contract negotiations broke down completely about a month later and, as of this writing, have not resumed.
Johns Hopkins, of course, is a major provider, so the breakdown had widespread consequences. Perhaps the most interesting aspect of this dispute is that it’s not about reimbursement levels.
Both Johns Hopkins and UnitedHealthcare have confirmed that they came to an agreement about reimbursement rates. Instead, this dispute is about contract terms. The parties’ respective statements do not agree about the specifics, but the following items have been mentioned:
- Prior authorization requirements;
- Exclusion of coverage on a group-by-group basis;
- Claims processing methodologies; and
- Reimbursement time frames.
This dispute gives outsiders a good look into the provider network contracts themselves, which are far more complex than most people realize.
So what exactly goes into a provider contract?
PayrHealth and Sirion cite the following provisions as being included in a provider contract:
- Reimbursement rates;
- Reimbursement time frames;
- Claims processing time frames and methodology;
- Definitions of “medical necessity”;
- Performance and quality metrics;
- Network participation requirements;
- Regulatory compliance; and
- Dispute resolution.
Sirion has a list of things that providers should check on their web site, and PayrHealth cautions providers about “hold harmless” clauses, which determine who’s responsible in case something goes wrong. In addition, a recent article on Insurance NewsNet lists three potential problem points for carriers:
- “All or nothing” clauses, which require carriers to either cover care at all hospitals in a hospital network (such as the Johns Hopkins Hospitals) or none of them;
- Anti-tiering provisions, which mean that carriers cannot treat in-network providers as “preferred” and “non-preferred” (a quality and cost measure), thus creating the impression that some in-network providers are “better” than others; and
- Anti-steering provisions, which allow carriers to offer richer coverage at other providers or facilities.
Looking only at reimbursement levels tells only part of the story. Provider network contracts govern nearly every aspect of the relationship between a health carrier and a medical provider, and negotiations can falter over any number of those provisions.
For employers and members trying to understand why a provider leaves a network, it’s worth remembering that the dispute may involve far more than simply “how much the carrier pays.” That may, in fact, be the least contentious part of some contract disputes.