I always tell clients it doesn’t matter how good your insurance is on paper if you can’t use it.

In July, I attended a meeting at Cape Fear Valley Hospital where CEO Mike Nagowski and Vice President of Managed Care Bart Fiser announced that due to critical grievances in service, CFV was terminating the UnitedHealthcare Medicare Advantage network at the hospitals and in 2024, all their other providers as well.

Hospitals often have these disputes with insurance carriers. Last year, Duke Wake Med terminated their relationship with UHC for about six months.

This past February, Charlotte Ears, Nose and Throat also announced that they would be terminating UHC unless negotiations were made.

There are plenty of examples in North Carolina alone, but the situation at Cape Fear Valley has one major difference from what is typical in these situations: it isn’t about money.

Mr. Fiser painted a grim scene of doctor frustration and administrative nightmares, and he claimed that Cape Fear Valley patients were receiving around a 30 percent decline rate of services with UHC Medicare Advantage plans, including things like pacemakers.

Furthermore, prior approval was being downgraded months later. A diagnosis of sepsis being downgraded to pneumonia because it didn’t meet the carrier definition was an example I was provided with.

Mr. Fiser also explained that transmitting medical records to UHC was particularly vexing because the online portals often won’t accept files as large as necessary to transmit data.
Oftentimes, CFV must mail paper copies costing as much as $800 and increasing the turnaround time on decisions.

These high declination rates, administrative difficulties, and reneging on prior approval have been so detrimental to patient care that the executive team felt forced to cut ties.

“I didn’t ask for a single penny. We get higher rates with UHC. We were in partnership with them on shared savings. Denials just got so crazy.” said Fiser.

On October 5th, I met with Mr. Fiser again to see if there were updates that would provide me with insights I could use to better serve my clients. One of my questions centered around PPOs. I had spoken with agents and people in the community who had voiced that if they switched to a UHC PPO plan, they would be fine.

Mr. Fiser stated they “absolutely would not be fine.” While the hospital would accept the PPO plans, they would only do so at an out-of-network rate.

I inquired if any headway had been made to repair the relationship and was told there had been none but that “we would certainly listen if they addressed the issues because we want what’s best for the community.”

I point-blank asked Mr. Fiser if there was a carrier they did not have issues with, and he replied, “we don’t have issues with Blue Cross Blue Shield.” No others were specifically mentioned.

During this annual enrollment period, make an informed decision on your plan for 2024 because, to quote Mr. Fiser, “people don’t want to drive 75 miles for service.”