“DISCLAIMER: The Society or this office does not provide legal advice to members, and the letters provided here should not be relied upon as legal advice. We recommend that you consult with healthcare counsel.”
PHYSICIAN TO PATIENT LETTER - TEMPLATE
To my PLAN NAME Patient:
If you or your family members are participating in one of the new NYS Health Benefit Exchanges offered by United HealthCare, Empire Blue Cross Blue Shield, or EmblemHealth, you may have recently seen a letter or, you may have heard that Iwill no longer be part of that plan’s network.
We want to make it clear that the decision to remove me was made by the insurer, not by my office. Unfortunately, the insurer is removing a number of physicians who are top-rated for quality and efficiency. They have not afforded me any appeal rights. However, I am appealing the insurer’s decision anyway, but we do not know if the appeal will be heard, let alone granted.
I take very seriously the issue of access to care for my patients and everyone in the community, and I very much wish to still be able to care for you. With this in mind, I need your help in contacting your insurance plan using the template letter below.
We will be happy to discuss any questions you may have and we very much hope that we can continue ourrelationship.
Doctor ______
PATIENT TO INSURER LETTER – TEMPLATE
(Note to physician: You may wish to gather letters written by your patients to the insurer, and include them with your appeal. Following is a template letter for you and patients to adapt :)
Dear [Insurer] _____,
As a patient of Dr. ______, I would like to say that I am extremely concerned and angry about your decision to exclude my doctor’sparticipation in the new Health Benefit Exchange plan, [name of plan] ______, in which I am enrolled.
I very much need to continue receiving care from my physician, because ______.
If I am forced to choose another plan in which Doctor ______participates, I will have to take that step. However, it will be difficult for me to accomplish this. But I will try to do so, which means your company will lose me as a subscriber. In addition, I will be contacting my elected representatives in Congress to let them know about this problem.
PHYSICIAN TO LEGISLATOR LETTER - TEMPLATE
Dear Senator/Congressman ______:
This letter is to alert you to a pattern that is becoming widespread here in New York State that could have a huge impact upon our patients’ continued access to needed care. As you may have read or seen in news accounts in the New York Daily News, New York Post and CBS-2, several commercial insurers in downstate New York, including Empire Blue Cross Blue Shield, Emblem Health, and United Healthcare are “deselecting” or excluding many individual physicians from the new Health Benefit Exchange plans.
Sick patients are losing longstanding relationships with their physicians. And it’s happening even where the physician performs special procedures that aren’t done by many other physicians, or is part of a special, necessary program in the geographic area.
Plans cite “administrative” reasons, but we have serious concerns about the adequacy of the networks that result, and about the threat to the citizens of this state’s access to quality care. This problem must be investigated further.
More importantly, I have been afforded no appeals rights by this insurer to challenge their decision to exclude me from these Exchanges!
I urge you to continue to convey these concerns to the Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS), your legislative colleagues and to the President!
We need to protect our patients’ ability to continue to see the physician of their choice, and maintain the continuity of care they deserve.
Sincerely,
Doctor _____
APPEAL TEMPLATE
(Note to physician: Be sure to review the various choices and optional material included in the following template. Use what suits your practice and delete the rest.)
Dear _____,
I am writing in regard to your recent letter exercising your contractual right to exclude me from the new Health Benefit Exchange plans. These actions involve the following plan(s): ______. I wish to continue to treat patients as a participating physician, as I feel that I am, and have been, a valuable asset to the(se) network(s); this action by your organization to terminate me from these plans will definitely result in access to care problems for my patients and your subscribers.
Therefore, this letter serves as my formal appeal of your decision, and I request that this appeal be handled (CHOOSE ONE)based on the information contained in this letter. through a formal hearing, by telephone or in person, with the appropriate members of your staff.
The services I provide are important and needed in your network: I see approximately ______subscribers who are enrolled in the ______Plan, and have participated in the ______Plan for ______years. Most of these ______Plan enrollees are elderly or infirm. All suffer from chronic diseases unique to this patient population and require my constant attention and monitoring. Your actions will have a significant effect on my patients (your subscribers), and on my ability to continue to provide them with critical and much needed medical care.
My practice focus is on the treatment of(INSERT INFORMATION HERE).
These conditions often require sophisticated diagnostic tools, tests and other involved processes, in order that I may deliver the best care for my patients. I am one of the few who utilize the (IF APPLICABLE, INSERT INFORMATION HERE).
My practice is in an area that has a large and unique population of patients who suffer from (IF APPLICABLE, INSERT INFORMATION HERE) and I am active in a program that works with these patients.
My practice delivers high-quality medical care to your subscribers, and I have been involved in, not only the Medicare based Physician Quality Reporting System (PQRS), but also the quality reporting plan used by (IF APPLICABLE, INSERT INFORMATION HERE).
Patients will be severely disadvantaged by your action: If your action stands and I am forced to discontinue treatment, my patients will suffer and may be subject to even graver consequences if access to their healthcare is interrupted.
The need to resolve this situation is critical, and I am available to discuss this issue with your office at any time. I want to ensure that my patients do not suffer any negative consequences as a result of your decision to remove me from the panel and put an end to the much needed care I deliver. I urge you to reinstate me in your ______plan(s).
Thank you,
(SIGNATURE & CONTACT INFORMATION)
Cc: XXXXXX