Your health insurer is now out of network at nearby hospitals. What are your options?

Contract showdowns between hospital systems and health insurers are happening more often, and patients are caught in the middle.

In recent months, disputes over expiring contracts have led to tens of thousands of South Florida residents receiving state-required warning letters from their insurance companies, alerting them that their physicians or local hospitals could soon be out of network. If the insurer and health system fail to reach an agreement, patients lose access to trusted doctors or face significantly higher medical bills.

In some cases, disputes escalate beyond a warning letter. For instance, in Broward County, Broward Health and Florida Blue failed to reach a new contract agreement by July 1. That conflict caused Broward Health’s hospitals, emergency rooms, physicians, and specialists to be out of network, affecting 18,000 Florida Blue members.

“Hospitals are aware of how disruptive this is to patients, and they don’t like to do this, but it’s a last resort when the dynamic is so bad the hospital can’t continue to provide treatment on the insurer’s existing terms,” said Doug Wolfe, a healthcare attorney with Wolfe Pincavage in Miami.

Hospitals argue they need higher reimbursement rates to cover escalated costs such as supplies and labor, while insurers claim rate increases would lead to unaffordable premiums for consumers.

“We are seeing a lot of finger-pointing,” said Jamie Godwin, senior analyst with KKF, a health policy research, polling and news organization. “The health system will say the insurer is being unreasonable, and the insurer is saying the same thing. They make it seem like the other is walking away from negotiations. However, both sides typically have an incentive to come to a deal.”

While the patients may not have a seat at the bargaining table, they bear the consequences when negotiations break down.

Mitch Hirsch of Parkland is furious about the contract dispute between Florida Blue and Memorial Healthcare System that could put 31,000 patients out of network.

Hirsch’s wife recently was diagnosed with cancer by a Memorial Healthcare doctor, but he has been turned away in his attempts to make her an oncology appointment at the health system because she has a Florida Blue PPO plan. Memorial Healthcare System’s contract with Florida Blue expires on Sept. 1 and no agreement has yet been reached.

Memorial’s website says the health system will not make appointments for Florida Blue enrollees on or after Sept. 1, 2025, until an agreement is reached.

“It’s disgusting,” Hirsch said. “It’s not about patient health. It’s about money.”

South Florida has seen multiple high-profile standoffs in recent years, with some resolved only hours before contracts expired. In December, Holy Cross Health in Fort Lauderdale reached a new multi-year agreement with Aetna, a day before the contract was set to expire on Jan. 1 and cause policyholders to lose their in-network access to Holy Cross Health facilities and providers.

South Florida’s disputes mirror a national trend: The number of contract conflicts between insurers and health systems in the U.S. has been on the rise as contracts expire. According to data from FTI Consulting, a business advisory firm, there were 133 total disputes in 2024, compared to 86 in 2023 and 51 in 2022.

Each time these disputes happen, patients endure the anxiety of not knowing whether their hospital or physician will remain covered. Some patients — especially those in the middle of cancer care, pregnancy, or chronic disease management — fear interruptions in treatment. Others brace for out of network costs that can run into the thousands of dollars. More than 31,000 Florida Blue policyholders recently received warning letters that they could be out of network if a new contract with Memorial Healthcare System isn’t signed by Sept. 1. Another 20,000 policyholders were moved out of network earlier this year in the Broward Health system.

Florida Blue told the South Florida Sun Sentinel: “With our current contract set to expire in days, we’re disappointed that our valued partnership with Memorial Healthcare System remains unresolved, creating uncertainty for our members.”

Finding a new doctor and getting an appointment can take months, particularly for specialists.

Here are some frequently asked questions from patients:

Q.  Why do health plans send these letters about changing a health system from in-network to out of network in the middle of the year, rather than during open-enrollment season?

A. Hospitals don’t contract with insurance companies based on a calendar year.  Whenever a hospital and insurance company enter into a contract, they set an effective date. Even within a hospital system, there are different dates when agreements expire, explains Wolfe, the Miami healthcare attorney. Insurers and health systems start renewal negotiations a few months before the expiration, but if they can’t reach an agreement in time, the contract expires.

Q. What are the rules around informing patients on the status of negotiations?

A. By law, policyholders with government plans like Medicare must be notified 45 days in advance of a potential contract expiration and commercial plan holders must be notified 30 days in advance.

“There has to be enough advance notice so patients are able to guide their healthcare decisions accordingly,” said Steven Cowherd, a health care attorney and chair of Pullman & Comley’s Health Care practice.

As the Sept. 1 deadline looms for the Memorial Healthcare/Florida Blue contract expiration, Bob Pifer of Pembroke Pines said he has tried to get an update from both entities with no success. The insurance company’s website says “discussions are ongoing and productive, and we’re hopeful of reaching a resolution.”

Q. What does being out of network mean for a patient?

A. It means your hospitals, physicians, urgent care centers, and specialty facilities no longer have a contract with your insurer.  As a result, you will have higher out-of-pocket costs than if you receive care from an in-network provider.  The insurance company may not cover as much of the cost — or may not cover any cost.

Q. Do the doctors and hospitals have to take patients if they are willing to pay out of pocket for services?

In Florida, hospitals and doctors are generally not required to treat patients who are out of network, even if the patients are willing to pay the higher costs for services. “You can’t force a provider to take a patient; they have discretion on what patients they want to take, and if you are out of network, they may not want to take you,” said Marilyn Uzdavines, a professor of health law at Nova Southeastern University.

Q. What protections exist for patients in active treatment (cancer, pregnancy, chronic care) if their doctor goes out of network?

A. Florida’s continuation of care laws ensure patients can keep their healthcare coverage and treatment when a provider leaves an insurance network. Some plans may cover services for up to 60 days after a provider leaves a network, or for up to six months for HMO plans and 90 days for PPO members. It’s important to note that continuation of care typically applies to people who are in active treatment so they can continue to receive care, and excludes new treatment.

Q. If a hospital becomes out of network, what happens in an emergency?

A. In an emergency, a patient can go to the nearest hospital. Federal law protects patients against higher out-of-pocket costs when they receive emergency services and care — even if a provider is out of network. If someone is admitted to the hospital after an ER visit, and the hospital is no longer in the network, the hospital stay for the emergency is covered at the in-network cost share.

Q. Memorial Healthcare and Broward Health are the only not-for-profit pediatric hospitals in Broward County.  What happens if a Broward County child needs a specialist at one of those health facilities, and Florida Blue is their insurer?

A. For now, Memorial continues to take Florida Blue; however, it is not booking new appointments for specialists after Sept 1. Florida, like other states, has regulations concerning network adequacy in health insurance. Network adequacy requires health plans to provide consumers with reasonable and timely access to a sufficient number and type of providers, including specialists, within a reasonable geographic area. It is unclear whether this would apply if both not-for-profit health systems become out of network for Florida Blue policyholders.

“A plan has to deliver the product you are paying for,” explained Uzdavines at NSU. “They have to include enough essential providers in close enough geography and where you can get an appointment in a timely manner. If your plan does not meet that standard, you can file a complaint with the state.”

Q. If a dispute results in a provider being considered out of network, does that qualify as an exception when changing plans?

A. This could depend on the type of insurance plan and whether the plan considers the change a “qualifying event.” Government plans differ in their definition of a qualifying event from employer-sponsored plans. “You may be able to enroll in a different plan. But it really depends on the type of insurance,” Wolfe said.

Bernie Sobalvarro, a Broward insurance agent, highly recommends checking with your insurer. “You don’t have control of what insurance doctors or health systems choose to take, but there are always options,” he said. “You can always get private insurance as secondary insurance, and you can sign up for that anytime.”

Q. If my insurer and a health system reach an agreement, could a dispute arise next year that again puts my coverage in jeopardy?

A. It could, but it’s not likely. Cowherd, the health care attorney with Pullman & Comley’s Health Care practice, noted that contracts between health systems and insurance companies typically are for an average of three years. “We typically see a three-year agreement with cost increases tied to increases in the consumer index for health care or some other metric. So, each of the three years, there is some escalator.”

Cowherd said most often, the health system and insurance company eventually agree on a new contract, although it may take time. Sometimes, he said, the state attorney general gets involved and tries to bring the parties together.

South Florida Sun Sentinel health reporter Cindy Goodman can be reached at cgoodman@sunsentinel.com.