Court Keeps Injunction in United Medicare Advantage Case

A federal appeals court has refused to allow UnitedHealthcare to continue kicking physicians out of its Medicare Advantage plans. On Dec. 12, the court declined United's request to lift an injunction against the insurer and referred the case to a three-judge panel. The appeals court ordered the parties in the lawsuit to file briefs later this month. 

TMA and other state medical associations had asked the court to keep the injunction in place until the dispute in resolved in the courts.

The lawsuit originated in, and currently applies only to, Connecticut. However, attorneys for TMA and other medical societies are trying to expand the case nationally because physicians in Texas and other states are affected, said TMA Vice President and General Counsel Donald P. Wilcox. For example, he said, TMA has been told 1,100 physicians in Houston were notified they are being terminated.

The brief that TMA and the other associations filed says the appeals court should maintain the injunction because it "temporarily keeps in place the arrangements between United and physicians that have functioned for years." Terminating the physicians will cause them "irreparable harm," but keeping the injunction in place will not hurt United, they said.

United contends the injunction interferes with its right to manage its physician networks.

TMA and the other medical societies told the appeals court the lawsuit serves the interests of their members because "United's improper termination of physicians from the [Medicare Advantage] network would negatively affect other physicians, who would have to bear the burden of serving Medicare patients (at low Medicare rates) who would start coming to them in the absence of their regular doctors. This would place an undue strain on the physicians and practices left remaining in the network, and potentially compromise those providers' doctor-patient relationships with their other patients. In addition, under United's unilateral amendment justification, all physicians in United's networks remain subject to termination at any time and for any of United's products. Thus, in challenging United's use of this method of termination, the associations are protecting all of their members' interests."  

Besides TMA, state medical societies filing the brief included California, Florida, New York, New Jersey, and Tennessee. 

In November, TMA, the American Medical Association, and numerous national specialty societies and state medical associations told the Centers for Medicare & Medicaid Services (CMS) that United and other insurers were terminating physicians from Medicare Advantage plans. They said in a letter to CMS that such insurers are undermining patients' rights and denying them access to care. They asked CMS "to take immediate action" to make sure Medicare beneficiaries participating in these plans "have accurate and reliable information to make health insurance elections during the 2014 Open Enrollment period …"

The letter says hundreds of physicians reported they were terminated from the United Medicare Advantage networks. "The terminations are 'without cause' and have been timed in a manner that undermines the accuracy and reliability of the information Medicare beneficiaries are relying upon in order to make important health care decisions for 2014 health insurance coverage. The timing and process used to communicate the terminations and modifications to the networks are not consistent with CMS guidance and regulations," the letter says. 

They added that the terminations "will disrupt long-established patient-physician relationships, interfere with existing physician referral networks, and undermine emergency department coverage in many hospitals. Both the continuity and coordination of care will be negatively affected, and treatment for certain types of care commonly provided by a very limited number of sub-specialists may no longer be available within the network."

TMA and the others urged CMS to extend the Medicare Advantage open enrollment period and require plan sponsors that have reduced their networks to immediately:    

  • Provide and document that patients received actual and accurate notice of whether their current physicians will be in the 2014 network;    
  • Ensure that patients know they can retain their physician by choosing fee-for-service or by choosing a product with an out-of-network benefit if their plan provides one;   
  • Give physicians information they need to challenge network adequacy based on CMS regulations and extend the appeals deadline until physicians receive such information;    
  • Tell AMA and the state medical societies how many patients are impacted and which physicians were terminated; and  
  • Direct plans to hold all terminations initiated just before or during Open Enrollment 2014.  

Action, Dec. 16, 2013


Comment on this (Must be logged in to comment)

Add Comment

Text Only 2000 character limit

Looking for more?