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UnitedHealthcare denies forcing New Jersey members to use OptumCare provider

States where it operates Medicaid plans have asked for quality coverage while containing rising healthcare costs, insurer says.

Susan Morse, Managing Editor

UnitedHealthcare is denying reports that it dropped hundreds of doctors from its Medicaid physician network in central and northern New Jersey so it could push patients to Riverside Medical Group, a provider affiliated with OptumCare.

The changes made to its Community Plan network in New Jersey were unrelated to OptumCare's affiliation with Riverside Medical Group, UnitedHealthcare said. OptumCare is an important partner but just one of the thousands of provider groups included in UHC's networks across the country, the insurer said.

UnitedHealthcare and Optum are both part of UnitedHealth Group.

Physicians and Lawrence Downs, CEO of the Medical Society of New Jersey, told Kaiser Health News that UnitedHealthcare seems to be steering patients away from small, community-based doctors to large groups that they own. The Riverside Medical Group operates in the same area where physicians are being dropped.

UHC said that of the more than 14,800 physicians in its Community Plan network in New Jersey, only 2% practice with Riverside Medical Group. In 2019, it removed less than 2% of the physicians from the New Jersey Community Plan network.

WHY THIS MATTERS

The Kaiser report did nothing to help the image of insurers as large corporations looking at vertical consolidation as a way to boost provider control and profits.

Looked at another way, one reason UHC gave for making changes is to build a more focused network that enables better collaboration with physicians through value-based relationships. This improves outcomes and drives down costs, UHC said.

Another reason is to support state governments' objectives to maintain affordable, sustainable Medicaid programs, UHC said. The Community Plan network in New Jersey exceeds the state's network adequacy standards. Members have access to more than 5,400 primary care physicians and more than 9,400 specialists.

But for patients, losing a well-established physician relationship and starting  over with a new doctor can be a tough adjustment.

UnitedHealthcare said it understood that its members have personal relationships with their doctors and that network changes can be difficult. Members who wish to continue seeing their current physician should call NJ FamilyCare to discuss their options, UHC said.

THE LARGER TREND

UnitedHealthcare said it routinely reviews its networks and makes changes on an ongoing basis. Usually these changes are to the terms of its agreements with care providers, such as their reimbursement rates. In other cases, it is to reduce or increase the number of providers in its network.

Contractual disputes between providers and payers take place nationwide.

The disputes are often over the rate insurers are willing to pay physicians or when a payer decides to go with a narrower network.

One consequence has been surprise medical bills. A new survey from the American Society of Anesthesiologists confirms anecdotal complaints that proposed surprise medical bill legislation has coincided with a significant number of insurance contract terminations and unilateral lower payment adjustments by health insurance companies. The survey said anesthesiologists are being forced out of network as insurers cut rates by as much as 60%.

ON THE RECORD

"The states where we operate our Medicaid plans have asked us to support their efforts to provide quality healthcare coverage to their residents while also helping to contain rapidly rising healthcare costs," UnitedHealthcare said. "We take this responsibility seriously and are committed to being a good steward of state taxpayer dollars. Appropriate management of our network of care providers is one of the primary tools we use to help us meet this commitment to our state partners. We understand that our members have personal relationships with their doctors and that network changes can be difficult. Our priority is always to ensure our members have access to the care they need through a robust network of providers."

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com