UnitedHealthcare-Prisma Health impasse leaves patients out of network

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South Carolinians who have insurance through UnitedHealthcare will pay more for services from the state’s largest network of health care providers.

Prisma Health and UnitedHealthcare are at impasse over the reimbursement prices for services. Patients with UnitedHealthcare insurance will have to pay out-of-network prices.

In a statement made Jan. 2 Prisma Health placed the blame squarely on the insurance company. UnitedHealthcare did not respond to an SC Biz News request for comment.

“We are in this situation because UHC refuses to enter a reasonable agreement that reimburses us for the cost increases we have and continue to absorb for their health plan members,” the Prisma Health state said. “Prisma Health has been able to come to agreements with all other major insurance companies negotiated with during the past year, which recognize the increased costs that Prisma Health has incurred — all except UHC. This is just more evidence that Prisma Health is being reasonable, but UHC is not.”

Prisma Health serves almost 1.5 million unique patients annually in its 21-county market area that covers 50% of South Carolina. The company is based in Greenville but has a significant administrative and health services division in Columbia, with a network that stretches from the Upstate to the Mindlands.

Prisma Health says they made a proposal Dec. 26 and UnitedHealthcare countered the next day with a proposal that was essentially the same was the one before it.

“As with previous proposals submitted throughout our negotiation, UHC showed no good-faith movement in their last proposal and left the economics largely unchanged,” the statement said. “In our last communication to UHC on Dec. 30, we reiterated our commitment to enter an agreement that would maintain Prisma Health in-network and asked them to submit a reasonable proposal. UHC refused to do so, which resulted in them placing Prisma Health as out-of-network.”

Prisma Health also accuses the insurance company of using misleading information about the negotiations, including the sequence of events and the economics of the proposals.

Related content: Prisma Health in Greenville opens one of 9 new urgent care centers

“Specifically, UHC continues to reference ‘near 20%’ requested increases over 12 months,” Prisma said in the statement. “This is simply not true. Although it is our policy not to disclose specific details about our negotiations, Prisma Health’s requests to UHC have been less than 10% a year over a two-year timeframe. In addition, we have proposed alternative reimbursement mechanisms that would lessen the rate impact on employers. UHC has ignored those proposals. In addition, Prisma Health has requested Medicare Advantage rates consistent with market competitive reimbursement. UHC remains unwilling to sacrifice their own profit margin and provide appropriate payment rates for services we provide to patients covered by UHC Medicare Advantage plans.” 

Patients with a UHC Medicare Advantage insurance policy who want to continue to keep their relationships with the doctors they have been seeing have options by switching to a plan that includes Prisma Health as in-network during the annual open enrollment period. The annual Medicare Open Enrollment period runs Jan. 1 through March 31, the statement said. A list of Medicare Advantage insurance plans accepted by Prisma Health is posted on the Prisma Health website Prisma.Health/MA2024.  

“We remain at the negotiating table and ask that UnitedHealthcare provide a reasonable proposal that would quickly reinstall Prisma Health as an in-network option,” Prisma Health said in the statement.

Prisma Health is a private nonprofit health company with 29,500 team members, 18 acute and specialty hospitals, 2,947 beds, 300 outpatient sites, and more than 5,100 employed and independent clinicians across its clinically integrated inVio Health Network.