My next post on this blog was going to be about what to do if your doctor or health care provider leaves your carrier’s network. But KFF Health News beat me to it with an article appropriately titled, So Your Insurance Dropped Your Doctor. Now What?
Nationwide, contract disputes are common, with more than 650 hospitals having public spats with an insurer since 2021. They could become even more common as hospitals brace for about $1 trillion in cuts to federal health care spending prescribed by President Donald Trump’s signature legislation signed into law in July.
The article is well-written and covers the basics, but I do have a quibble with its item #2, when the article notes that rifts between hospitals and insurers often get repaired. It then goes on to state that most of those breakups ultimately get resolved within a month or two[.] So your doctors very well could end up back in the network after a split.
Historically, that’s not incorrect, but the recent Johns Hopkins/UnitedHealthcare and Memorial Healthcare/Florida Blue disputes both involved negotiating parties walking away from the table. The network contracts lapsed, and as of this writing, Johns Hopkins is still out-of-network with UnitedHealthcare and Memorial Healthcare is still out-of-network with Florida Blue. Some of the disputes I’ve picked up for the Network Contract Watch have included language suggesting more of this could happen.
At this point, it isn’t that contract disputes and lapses “could be” more common. They already are more common, and the situation is getting worse. I should also add that I’ve recently seen several situations where a new contract has not been retroactively applied, as the article implies, meaning that out-of-network claims from the lapse period will not be reprocessed as in-network claims.
In other words, I definitely do not recommend trying to “wait out” a contract negotiation split. Rather, if you get a notice, monitor the situation carefully, and follow the steps in the KFF Health News article to prepare yourself for what might be coming.
My other quibble is with item #3, which implies that exceptions exist without going into much detail. They do, but network exceptions are rare and they’re usually both temporary and limited. They also tend to require extensive paperwork. It’s never safe to assume you will qualify just because you have a chronic medical condition.
The industry term is continuity of care, and the qualifying list of conditions is short. The exact definition of “qualifying condition” varies by carrier and plan, but it might look something like the following:
- Cancer, when a patient is newly diagnosed or is in an current and active treatment such as a round of radiation or chemotherapy;
- Recent major surgery and the immediate follow-up period (usually about six to eight weeks);
- A recent severe medical episode such as a heart attack or stroke, when the patient is still in the follow-up period or is not yet stabilized;
- Organ transplant recipients who need ongoing care due to complications; or
- Pregnancy that has reached the second or third trimester. (This is actually the most common case where continuity of care is approved.)
Simply being under treatment for a chronic, but stable, condition generally is not sufficient to qualify for continuity of care; and outpatient mental/behavioral health treatments are usually excluded. Even when approved, the approval is usually for care for that specific condition only and will have a time limit. The assumption is that, if you require continuing care, you will transition over to a network provider in an orderly manner. There is also an assumption that you will visit a network provider for any new medical issue.
If you are dealing with a serious condition like the above, don’t wait to start the paperwork. As soon as you hear about a potential contract lapse, call the customer service number for your health coverage (it’s often on the back of the ID card) and ask for the continuity of care forms and information. The process usually involves multiple steps and likely will require medical records requests.
It’s important to note that in the case of a life-threatening emergency, you should always go to the nearest emergency room. Also, if you are already in the hospital on the day a network contract lapses, that entire stay will usually be treated as in-network.
Shortly before it begins its list of recommendations the KFF Health News article, quotes an expert who quotes a proverb: when two elephants fight, the grass gets trampled. That’s an apt description of network contract negotiations and their effects on health care consumers. The best thing they can do, then, is to remember another old aphorism: be prepared.