Senior citizens with Medicare Advantage plans through United Healthcare who had previously used The William W. Backus Hospital for tests and procedures are now traveling to other local hospitals for care because Backus no longer accepts that insurance plan.

Patients are able to seek an out-of-network exception in advance to have their care at Backus covered, but this can involve higher co-pays and extra paperwork. There are reports of some patients incurring unexpected charges because they did not seek an exception in advance.

The situation, which arose after Backus and the insurer were unable to reach an agreement on rates, was the subject of a recent inquiry by the state health care advocate, who acted on a complaint from a Norwich medical practice that treats many seniors.

Victoria Veltri, the acting health care advocate, said Monday that she concluded the case by asking United to inform patients and doctors that they can request an out-of-network exception in advance, and she has asked doctors to share that information "far and wide."

Exceptions would be granted on a case-by-case basis, provided their doctor is in the United network, United officials told the health care advocate in a March 22 e-mail. Veltri began the case March 18. She did not identify the practice that made the complaint.

About 1,500 seniors in New London County now have the United Healthcare Medicare Advantage plans, according to United spokesman Jonathan Stone, about half as many as the plans they replaced that were available until the end of 2010. The plans are accepted at Lawrence & Memorial in New London, Day Kimball in Putnam, Westerly Hospital, Windham Community Memorial, Manchester Memorial and Rockville General, among others.

The plans are also accepted at many physicians' offices in the region. The United plans are the successor to Medicare Advantage coverage provided by another insurer, HealthNet, until its acquisition by United in mid-2009. Through the end of 2010, Backus accepted HealthNet plans, but it was unable to reach a contract agreement for the replacement United plans because of a rate disagreement, Stone said.

Veltri said the doctors at the practice that made the complaint became concerned after sending patients with the United plan to Backus before they or the patients were aware that the plan is no longer accepted there.

"Patients came out of the hospital with huge bills, because they were treated as out-of-network," Veltri said.

Natalie Lindberg, outreach administrator at the Rose City Senior Center, said she has received many calls from seniors since the change took effect Jan. 1.

"It caught everyone off guard," she said.

Some were able to switch to other insurance plans that were accepted at Backus, while others began traveling to L&M or Day Kimball, she said. But Betty Koskee, deputy director for consumer education for Senior Resources in Norwich, said traveling farther from home for medical services is difficult for many seniors. In addition, their doctors in many cases are affiliated only with Backus.

Dr. Yogesh Katechia, a Norwich primary care physician, said several of his patients have gone to Backus or its affiliates for routine lab work, MRIs or other tests. When they learned they wouldn't be covered, they went to another hospital, and the doctor's office had to make arrangements to get the results. Getting an out-of-network exception, he added, involves extra paperwork and often higher co-pays for patients, so "it would not be a good thing for our patients financially."

Shawn Mawhiney, spokesman for Backus, said United initially invited the hospital to join the network, "but then United Healthcare informed us that they had reached an exclusive agreement with another hospital in the region and we would not be part of their network. It was disappointing to us and confusing to our patients, to say the least.

"We would prefer to be in their network," he said, adding that the hospital "would welcome the opportunity" to join in the future.

Mawhiney said the hospital sent letters this winter to 1,300 patients who had been covered by HealthNet, advising them that "individuals who are participants in United Medicare Advantage may have a higher financial responsibility for the cost of their care at Backus." But the hospital had no way of knowing the names of everyone with the United plans who may be coming to Backus for care, so "the word didn't reach everybody," Mawhiney said.

"It really shines a light on the fact that anybody who has a change in their insurance should read the paperwork that's given to them and make sure their hospital and doctors are in the network," Mawhiney said.

The hospital posted signs at registration desks stating that Backus does not accept United Medicare plans, and informed registration staff how to explain the situation to patients, he added.

j.benson@theday.com