It took Riverdale resident Kelly Foster years to get her Crohn’s disease diagnosed. Once she did, she sought out the specialists at Mount Sinai’s Inflammatory Bowel Disease Center to get it under control.
“Once I did that, it kind of made sense to just start moving all of my doctors [to Mount Sinai] so that it’s all in the same system,” said Foster, 58. “I moved my primary care over there and then I recently moved my gynecologist over there.”
Foster is one of thousands of patients facing the prospect of finding whole new care teams as Mount Sinai ends its relationship with UnitedHealthcare, her insurer.
When Mount Sinai and United ended their contract amid a dispute over billing rates at the end of last year, some patients with United immediately lost coverage at Mount Sinai hospitals, while others lost it this month, depending on their plans. But United is now upping the stakes beyond hospital care: It’s also removing Mount Sinai-affiliated doctors from its network effective March 22.
More than 80,000 New Yorkers covered by United have visited Mount Sinai hospitals or affiliated doctors in the past year, according to the insurer.
United says Mount Sinai is seeking a 58% rate hike over the next four years that would make it the city’s most expensive health system. But Mount Sinai says it is just trying to get paid rates that are closer to competitors like New York-Presbyterian to cover rising labor costs and other expenses. Despite ongoing talks, patients are still unsure whether they can expect their coverage through United to be restored.
Some patients say they’re trying to figure out whether they have medical conditions that qualify for extended coverage under state and federal rules around continuity of care. Several told Gothamist they’re putting off looking for new health care providers in the hopes that the hospital system and insurance giant will work out their differences.
“I’ve been Googling this every couple of days, like, ‘Is there any word?’” Foster said. “I just keep thinking they’re going to solve this.”
Foster said she made sure to schedule her annual gynecologist and rheumatology appointments for late last month just in case.
How to keep your doctor and avoid big bills
Antonia DeBianchi, 25, said Mount Sinai went out of network for her particular United plan in January — but she wasn’t aware until she got a $2,200 bill for an ultrasound. The Upper West Sider said she wasn’t able to get United to cover the bill but ultimately got it reduced through Mount Sinai’s financial assistance program, which is available based on a patient’s income.
DeBianchi ultimately paid just $272, according to the billing statement she shared with Gothamist.
Spokespeople for United and Mount Sinai said anyone experiencing billing issues as a result of the split should call with any questions.
Some Mount Sinai patients are weighing whether to pay out-of-pocket rates to continue visiting their current health care providers.
But some will be able to keep their doctors after the transition. Doctors typically have agreements with at least one hospital to admit patients. If a Mount Sinai-affiliated doctor also has admitting privileges at another hospital in United’s network, they’ll continue to be covered.
Mount Sinai doctors can continue to accept United insurance if they secure agreements with other hospitals, the insurer said. United covers a wide range of other facilities in the city, including hospitals associated with NYU Langone, NYC Health and Hospitals, and Northwell Health.
State and federal law also require United to provide extended coverage for some patients who are in the midst of treatment with Mount Sinai providers for up to 90 days after they go out of network — meaning those who qualify could potentially continue seeing their current doctors well into June. Patients who think they might be eligible should contact United to confirm.
The requirements patients must meet depend on the kind of health plans they have. Many employer plans are regulated by federal law rather than state law, which only provides transitional coverage to people who are pregnant or have “serious and complex” conditions such as cancer. Plans regulated by state law must provide that coverage regardless of a patient’s medical condition.
Some patients said they were either unaware of the continuing coverage rules or unsure of whether they qualified.
“It’s been an unmitigated disaster,” said Dr. Alan Adler, an OB-GYN at Mount Sinai. He said he had just delivered a baby for a patient who wasn’t sure whether her delivery would be covered until just a few days prior.
Adler blamed United for not giving patients timely answers about whether their care will be covered. But Cole Manbeck, a spokesperson for United, said the insurer is doing patient outreach to inform people of their benefits and anyone who’s unsure can call the number on their insurance card.
They could still reach a deal
Spokespeople for Mount Sinai and United say they are still in negotiations, but the standoff over prices continues.
The payments negotiated between hospitals and health insurers for medical services were once kept secret, but in recent years, new laws have required them to be posted online. Advocates for this type of price transparency hoped it would spark competition and drive down health costs — but, in this case, it may be doing the opposite.
Mount Sinai’s analysis of competitors’ rates was “very telling for us” and helped drive the request for higher reimbursement, said Brett Estes, chief managed care officer at Mount Sinai Health System, who has been involved in negotiations with United.
In communications with patients, Mount Sinai and United continue to point fingers at each other over who is responsible for the breakdown of negotiations. United has called Mount Sinai’s proposals “outlandish,” while Mount Sinai has said United refuses to engage with its “good-faith offer.”
The dispute between Mount Sinai and United offers a preview of what could be in store for Aetna members who get their care at New York-Presbyterian. New York-Presbyterian sent a letter to patients late last month saying its hospitals and clinical practices could be out of network with Aetna starting April 1 if they don’t reach an agreement on a new contract by the end of March.
Patients say they just want practical answers about their care.
“I don’t exactly know who I’m supposed to believe, but either way, no one is handling it well,” United member Caroline Aaron said.