UnitedHealthcare, WakeMed terminate contract

Beginning June 1, WakeMed is no longer a part of the UnitedHealthcare network.

Raleigh, N.C.-based WakeMed said it is ready to continue negotiations, but cannot agree to a contract "that enables an insurance company to determine the necessity of our patients' medical care," according to a news release.

UnitedHealthcare is the second-largest payer by market share in North Carolina, and the move is expected to leave 20,000 WakeMed patients out of network.

The impasse stems from payment practice language regarding medically necessary treatments. Rate change proposals have not occurred, according to WakeMed.

"I have personally witnessed terribly sick patients being denied insurance coverage by UnitedHealthcare while already receiving care in our Intensive Care Units," Seth Brody, MD, executive vice president and chief physician executive at WakeMed, said. "Our clinicians are doing their jobs at the bedside. UnitedHealthcare is simply looking to increase profits by complicating claims approvals and denying many claims after our patients have already received necessary medical care."

WakeMed first issued a termination notice in November and has since provided one comprehensive proposal throughout negotiations, a UnitedHealthcare spokesperson told Becker's.

UnitedHealthcare sent rate proposals to WakeMed in December and March, but never received responses. In 2021, WakeMed proposed a 20 percent rate increase in the contract's first year, but did not discuss specifics with UnitedHealthcare, according to the spokesperson.

"Based on WakeMed's actions over the past several months, we can only assume it was always the health system's intent to disrupt access to care for North Carolinians. We've made numerous attempts to compromise and find solutions as part of good-faith negotiations," the spokesperson said. "Unfortunately, WakeMed chose to cancel our contract, declined our offer to extend our current agreement, and never countered the multiple rate proposals we've provided since December. We will stay at the negotiating table as long as it takes to renew our relationship. We urge WakeMed to join us there and work toward a solution that is in everyone's best interests."

The spokesperson added that approximately 90 percent of WakeMed's claims submitted over the last year were approved, and 75 percent of those denied were due to an administrative error by WakeMed. WakeMed has reportedly refused to negotiate regarding a Medicaid contract until UnitedHealthcare agrees to the commercial requests. Approximately 96 percent of the state's hospitals are in UnitedHealthcare's Medicaid network. Three of the five total hospitals not in network are WakeMed facilities.

Going forward, WakeMed said all patients will be able to seek treatment at any of the provider's seven emergency departments and primary care physicians will remain in-network for clinic visits. 

UnitedHealthcare community plan members will still have access to WakeMed's facilities and physicians for all services and will be reimbursed as an out-of-network provider, the UnitedHealthcare spokesperson said.

WakeMed's facilities include three full-service hospitals, seven emergency departments, a dedicated children's hospital, a rehabilitation hospital, more than 80 physician offices and a level 1 trauma center. WakeMed has 1,300 affiliated physicians and employs more than 580 physicians.

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