Patients with Humana’s Medicare Advantage or commercial health insurance plans already lost in-network status — which is generally more affordable than out-of-network rates — for Baptist Health Medical Group. The group includes over 1,100 clinicians in Kentucky and Southern Indiana.
That happened last month, after Baptist and Humana did not reach an agreement by their Sept. 22 deadline.
Now, Baptist confronts a different deadline with two other insurers: Dec. 31.
On its website, the Louisville-based health system says it has been working for months to secure new agreements with UnitedHealthcare and Wellcare for their Medicare Advantage plans.
“Our goal is to protect our patients’ trusted relationship with their physician or provider and their in-network access to the high-quality care they need,” Baptist spokesperson Rebecca Brown said in a statement.
Without new contracts, Baptist says it will go out-of-network with UnitedHealthcare and Wellcare’s Medicare Advantage plans after the Dec. 31 deadline.
Only Baptist Health Medical Group went out-of-network with Humana’s insurance plans. But that group of clinicians, along with Baptist’s hospitals, home care and outpatient clinics, would all lose in-network status with UnitedHealthcare and Wellcare’s Medicare Advantage plans if a deal isn’t reached.
UnitedHealthcare spokesperson Spencer Leuning told LPM News the organization’s top priority is to “renew our relationship with Baptist Health and ensure continued, uninterrupted access to the health system” for people enrolled in its Medicare Advantage plans.
“We are committed to continued good-faith negotiation and utilizing the two and a half months remaining on our contract to reach a new agreement,” Leuning said.
Wellcare did not respond to a request for comment.
A chart available on Baptist’s website indicates the health system also is in negotiations for:
- Anthem’s Medicare Advantage network in Indiana and Kentucky.
- Passport by Molina Healthcare’s Medicare Advantage plans, specifically for the Hardin, Louisville and La Grange markets.
It’s unclear if or when patients with Anthem or Passport’s Medicare Advantage plans could lose in-network coverage for Baptist providers.
In a statement to LPM News, Anthem spokesperson Jeff Blunt said a contract is in place that provides their Medicare Advantage members with in-network coverage at Baptist and “no termination of that contract has been discussed.”
“Therefore, we are confident of our Medicare Advantage members’ access to high quality, affordable care at Baptist Health for years to come,” Blunt said. “As with all our health system partners, Anthem is committed to our ongoing work together with Baptist Health to move toward a value-based health system that incentivizes quality outcomes over quantity of services.”
Molina Healthcare did not respond to a request for comment.
Brown, Baptist’s spokesperson, said they “continue to negotiate in good faith” with the insurers.
“While these conversations are at various stages, we remain hopeful we’re able to reach new agreements before the end of the year to avoid any disruption of in-network access,” she said.
For patients who want to preserve their in-network access to Baptist providers, Baptist said they could consider switching to an alternative insurance plan. Medicare’s open enrollment period runs from Oct. 15 to Dec. 7.
Baptist cites concerns about insurers’ denials and delayed payments
Baptist says the “most important issue” in its discussions with insurers is “to safeguard the patient-physician relationship.”
“It is our experience – and the experience of other healthcare providers across the country – that many Medicare Advantage plans routinely deny or delay approval or payment for medical care recommended by a patient’s physician or provider,” Brown said in a statement.
“We think the need for medical care should be determined by a patient and his or her doctor, not an insurance company.”
Medicare is a public health insurance program the U.S. government provides, largely for people ages 65 and up. But patients can pick a privatized option, called Medicare Advantage, that’s provided by insurance companies and can offer additional coverage benefits and lower out-of-pocket costs.
Medicare Advantage has become increasingly popular over the years, but it also has been scrutinized by government officials for a variety of reasons.
A 2022 federal inspector general report said Medicare Advantage organizations “approve the vast majority of requests for services and payment” but also “issue millions of denials each year.”
It said federal audits “have highlighted widespread and persistent problems related to inappropriate denials of services and payment.”
The 2022 review estimated denial rates based on a small sample of denials for payment or for prior authorization, which is when a patient’s insurer must sign off on a treatment before it can be provided.
The review determined Medicare Advantage organizations “sometimes delayed or denied” access to services for insured patients, “even though the requests met Medicare coverage rules.”
American Medical Association President-elect Dr. Bruce Scott, of Kentucky, said problems with prior authorization are an industrywide issue, arising with most private insurance plans and many public plans.
“The story that you’re hearing out of Baptist Health Louisville, we are hearing all across the nation,” he told LPM News. “And it’s one of the reasons why we’re pushing really hard in Washington, D.C., for a federal fix for this problem.”
Scott said the average primary care physician and their staff spend around 13 hours a week dealing with prior authorization. Denials by insurers — for Medicare Advantage or other insurance plans — impact their patients.
“And for many patients, when the insurance company refuses to cover the medication, the diagnostic test or the surgery, that means the patient isn’t going to get it,” he said.
