When Managed Care Plans Hang Patients Out To Dry

A couple of years ago a Medicare advantage insurance plan came steam-rolling into town and began signing up patients with a vengeance. They offered a whole host of freebies like band-aids, glucose strips, plush toys, you name it. They also had an offer that couldn’t be refused by seniors: no co-payments, no deductibles, and low premiums, i.e, ‘Free Healthcare’.

Needless to say, patients went gaga for this ‘great new company.’ Smaller practices had no choice but to sign up as well, for pennies on the dollar of the usual Medicare rates. Other doctors in our specialty signed up under these new rates as well, but we held our ground. We were the only group practice in our specialty in town and we refused to bite off on their low reimbursements.

Eventually they signed up several thousand of our patients. We reconsidered but we drove a hard bargain. Finally they offered us a premium over the other practices since we had the only subspecialists in the area. Worse than Medicare rates but something we could live with.

As soon as our practice signed up with this insurance company, the flood gates really opened. They used our practice on their marketing materials to sign even more patients. I think you can figure out what happened next.

About eight months later, this insurance company called to inform us that they were renegotiating our terms on a capitated basis, which would come out to about 50% of the Medicare rates. Naturally we refused to accept this. At which point we were told that “since we had decided to cancel our agreement” we could no longer see our patients enrolled in their plan.

This did not sit well with one of my partners, who had to deal with patients with significant medical and surgical issues and had no outside physician still on the plan who was qualified to take over the care for these patients. Which made him ultimately liable for their well-being. Unfortunately, he expressed his disgust of the insurance company to some of these patients and told them to complain to the their carrier for dropping their doctors. This is when we received a call from their legal department with a stern “cease-and-desist” warning: we were not to discuss the details of the termination of the contract; we were simply to tell patients that it was a “mutual decision.”

The practice that was enrolled to take care of these patients was based in another city. They placed itinerant physicians in a little rented office a couple of days a week. The service was sub-standard. The medical care was thin. Oh, and they also ripped off the name of our practice (they changed it after we got some copyright lawyers involved). A couple of their doctors actually called us to complain about the company they were working for and apologized for the situation that their company put us in.

Fast forward a year and you know what comes next: the Medicare Advantage plan has pulled the plug on their operation here and left several thousand patients in the lurch. These patients were not able to change insurance until the end of the year, when open enrollment rolled around, and had to go out of town if they wanted surgery. They are now slowly trickling backĀ  into our practice, albeit in many cases with inadequately controlled disease or worse.

Have you had a similar experience with a Managed Care company? Leave us a comment below. Oh, and this point bears repeating: make sure someone in your office with expertise in insurance opens all correspondence from insurance companies, managed care companies in particular. Read Dirty Tactics of Those Medicare Advantage Plans.

About Peter Polack

Peter J Polack is founder of Emedikon, a consulting firm specializing in medical practice marketing systems and president of Protodrone, a software development company specializing in medical practice applications. A technology columnist for Ophthalmology Management Magazine, he is also a managing partner for a large multi-specialty ophthalmology practice in Florida.

Facebook comments:


  1. […] Emedikon LLC for Medical Practice Trends, 2010. | Permalink | No comment | Add to del.icio.us Post tags: capitation, Insurance, managed care, practice […]

Speak Your Mind