Thousands of area residents may soon find that the only hospital in Coweta County is considered out-of-network.
Unless negotiations are successful, Piedmont Healthcare including Piedmont hospitals in Newnan, Fayetteville and Atlanta will terminate the agreement with Humana Medicare Advantage effective Sept. 7.
Pete Pedersen, 82, a Newnan resident said he received a letter from Piedmont informing him of the problem and asking him to contact Humana to tell the company how important an agreement with the health care system is to him.
“It’s alarming,” Pedersen said. “I’m sure there are thousands of people this is alarming to.”
Nicole Dillon, senior communications specialist for Piedmont Healthcare, said the issue is with Humana’s Medicare Advantage plan, not other Humana plans. The information about the termination is available online, including a list of Medicare Advantage plans that the system does accept, she added.
“The ability for Piedmont to provide quality care to the patients we serve depends on many factors, some of which are the responsibility of the insurance company. This includes timely approvals for medically appropriate treatments and for medically appropriate transfers to differing levels of care,” Dillon said by email. “Because we have been unable to reach resolution with Humana on such aspects of care, despite repeated attempts to do so, we have provided notice of termination of our hospital agreement with Humana’s Medicare Advantage plan.”
She was unsure how many of their patients are covered by the plan. Humana also didn’t provide that information, but did say that the negotiations are ongoing.
“Humana is currently in negotiations with Piedmont to reach a new agreement prior to the effective date,” Nancy A. Hanewinckel, Humana East Division media relations, wrote in an email.
“This does not affect Piedmont’s physician agreement with Humana nor participation in commercial products,” she added.
Managed care negotiations are typically initiated in the last year to six months of a contract between an insurance company and the health care provider, Anna Adams, executive vice president of external affairs for the Georgia Hospital Association, said by email. The negotiations include the way the insurance reimburses the health system, but the types of things negotiated are changing, she wrote.
“In recent years, hospitals and health systems have attempted to negotiate provisions that ensure that all the types of services it offers that are considered in such an analysis continue to be covered by the plan throughout the term of the contract,” Adams wrote. “Recent trends across health plans have made this part of the negotiation necessary as plans have increasingly disrupted patient care by moving certain services to subcontractors or other providers without consideration of the impact on patients or on hospitals.”
Additionally, hospitals are trying to protect care that a physician feels is necessary for a particular patient, but health plans may have policies in place that deny the treatment for administrative reasons, she added.
“Sticking points in negotiations often center on the overall financial impact of proposed rates, including the impact of a plan’s administrative policies, as opposed to a specific rate for a certain type of care,” Adams wrote.
While Piedmont Healthcare said in its notification that people will not be turned away based on insurance or ability to pay, Pedersen said he is concerned.
Should negotiations fail, he is stuck until December when he can look into changing insurance companies, Pedersen said. It is unlikely that he will be able to stop care for three months while he waits, Pedersen added. He is receiving treatment for heart failure, kidney failure and esophageal cancer — he just finished chemo and radiation treatments.
So on top of his health concerns, he is now worried about money.
“If we have to go to the hospital, it will be considered out-of-network, and you know how expensive that can be,” Pedersen said.
