Clark doctors dropped from Medicare coverage

Springfield-area seniors could need new doctors after insurance company’s decision.

Thousands of Clark County senior citizens might have to switch doctors or get care outside the county because of UnitedHealthcare’s decision to eliminate local physicians as part of its Medicare Advantage provider network in Ohio.

UnitedHealthcare would not release the number of physicians affected by the decision, but doctors here said it could touch virtually every medical specialty service in Clark County.

At least 50 Clark County doctors have received termination letters from the insurance company, informing them of the decision, according to local doctors.

Dr. Rick Nedelman of Surgical Associates of Springfield said the change will affect about 450 to 500 patients within his practice. He’s planning to appeal the decision.

“It’s disturbing to both the physicians and the patients,” Nedelman said.

Medicare Advantage plans are offered through private companies that contract with Medicare, typically providing all medical and prescription drug coverage.

“What we are doing is focusing on those providers who can have the most positive impact on the quality of care for our Medicare beneficiaries, while also dealing with the financial pressures created by severe cutbacks in Medicare Advantage funding,” said UnitedHealthcare spokesman Kevin Shermach.

Patients are receiving letters notifying them which doctors are being dropped and which doctors may be able to see them in the future. Patients will have to seek new insurance carriers if they wish to stay with doctors, even those who have provided long-term care.

Shermach said the basis for removal from the network is driven by what UnitedHealthcare is trying to achieve and “not necessarily by a failure to meet any contractual terms.”

“To not know why and not have an explanation why, I think is confusing and frustrating for physicians,” said Todd Baker, director of personnel services for the Ohio State Medical Association.

UnitedHealthcare has an estimated 100,000 Ohioans enrolled in six Medicare Advantage programs, although many won’t be affected by the changes, according to company representatives.

Baker said it’s one of the largest “widespread terminations” the state medical association has seen in recent years. It’s affecting doctors in southwest, central and northeast Ohio, though it’s “hard to know” how each community will be affected, Baker said.

Baker said the state medical association is recommending physicians appeal the decision and inform patients about the possible loss of coverage.

Baker said UnitedHealthcare has a contract with the Center for Medicare and Medicaid Services to insure an adequate provider network for its customers. Baker said the recent cuts make the state medical association question if the network is adequate, given the amount of practices they’ve heard from.

“We’ll certainly be working with others to ask the federal regulator if everything is still good here,” Baker said.

Ruth Karsten, an 87-year-old Springfield resident, said she and her 85-year-old brother, Charles Burgert, are without any doctors due to the change. They both receive insurance from the American Association of Retired Persons.

“It’s been very upsetting,” Karsten said. “You have no idea how stressful this has been.”

Karsten said three of her doctors – gastroenterologist Dr. Abdur Rauf, family practice physician Dr. Richard Gordon and eye physician Dr. Trent Carroll – have been dropped from the provider network.

She’s in the process of switching doctors through the insurance company, but called it “tedious.” She’s also helping doctors appeal the decision.

“It’s taken its toll on us,” Karsten said.

Nedelman believes insurance companies are shrinking the network to help save money and maintain profits. By reducing the number of doctors, it will take patients much longer to receive access to healthcare.

Community Mercy Health Partners spokesman Dave Lamb said the organization has not been notified of any doctors employed by CMHP who have been dropped from the Medicare Advantage network.

“We simply do not know what impact this might have on the hospital at this point,” Lamb said.

The state medical association has heard from some doctors employed by hospitals who have been terminated from the network.

“We really won’t know the answer to the question unless there’s a more comprehensive list,” Baker said.

The decision could force patients to go outside Clark County for specialty care. If travel becomes a concern, patients could decide to not seek care.

Midwest Nephrology and Hypertension is the only area nephrology practice outside of Dayton and Columbus, according to Dr. Sanju Varghese, who is also being dropped by UnitedHealthcare.

“When they drop us, they’re essentially telling our patients, including dialysis patients, they’re going to have to drive 30 miles to get their kidney care,” said Varghese.

Varghese, who’ll serve as the chief of staff at Springfield Regional Medical Center beginning in January, said insurance companies should not be able to dictate how doctors can provide care. He advised residents affected by the changes to write congressmen to figure out a solution for Medicare issues.

Without a doctor, Karsten said she and her brother may not be able to receive prescriptions. She’s also concerned about having to travel to out-of-town doctors. She’s spoken with several people who are having similar issues.

“The whole thing is the most upsetting thing I’ve had to go through in a long, long time,” Karsten said.

UnitedHealthcare encourages Medicare Advantage plan members with questions to call 1-888-332-8883.

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