Protecting Your Patient Rights

WakeMed is Out of Network for Commercial & Medicare Advantage Plans

Commercial contract negotiations continue in hopes of reaching an agreement.

At WakeMed, we never compromise when it comes to delivering high-quality patient care. In the interest of patients and our community, we negotiate insurance agreements in good faith and do not back down from the commitments we make. In return, we only ask that insurers honor their side of those agreements.

For nearly a year, WakeMed has been working in good faith with UnitedHealthcare to come to a contract agreement that ensures your continued in-network access to high-quality care and services with the WakeMed providers you know and trust. Unfortunately, we have so far been unable to reach an agreement.

As a result, WakeMed hospitals, outpatient facilities and physician specialists are now considered out of network for UnitedHealthcare. This change will impact out-of-pocket costs for most patients with UnitedHealthcare insurance. If you have an upcoming appointment at WakeMed, please review your options and next steps.

Please note that WakeMed primary care physicians are not included in these current negotiations and will remain in network.

If You Need Emergency Care

Please be aware that all patients, regardless of their insurance status, may still seek treatment at any of WakeMed’s eight Emergency Departments, including the county’s only Children’s Emergency Department.

Under the No Surprises Act, emergency services must be covered by the patient’s insurer without prior authorization, regardless of whether the facility/provider is in-network or out-of-network, and without regard to any other term or condition of the patient’s insurance plan or coverage.

This means that patients will pay the same amount for emergency care and post-stabilization services (including inpatient admission from the Emergency Department, if needed) as they would if WakeMed were in-network with their insurance plan. Patients do not need to transfer to an in-network facility once the emergency medical condition is stabilized to benefit from the financial protections of the No Surprises Act.

Where Negotiations Stand Currently

While our contract has not been extended, and WakeMed is currently out of network, WakeMed and UnitedHealthcare have agreed to continue negotiations around commercial contracts and meetings are ongoing. WakeMed remains open to reconvening Medicare Advantage negotiations should UnitedHealthcare offer reasonable language and terms.

We will continue to work in good faith with UnitedHealthcare to reach resolution, and we will also help you navigate any insurance-related challenges to help you get the care you need.

What These Negotiations Are About

In 2022, WakeMed and UnitedHealthcare (UHC) reached an agreement that was meant to address UnitedHealthcare’s excessive practice of denying payment for medically necessary care that we provide patients. Unfortunately, UHC has not honored the contract they agreed to and instead have consistently put their need for profits above the needs of their members – our patients.

Over the past three years, UHC has continued to deny care at rates 2-3 times higher than other insurers. These denials often occur after care has been provided, leaving patients caught in the middle and requiring WakeMed to dedicate significant resources to disputing these denials, on your behalf.

Below are just a few examples – among many – of denials we have received from UHC where they refused to pay for the medically necessary care provided. As you will see, it often takes several years to reach a conclusion on these issues. Fortunately, WakeMed provided the appropriate quality care in each situation regardless of insurance reimbursement.

• A 48-year-old patient required a 23-day inpatient physical rehabilitation stay, which was authorized by UHC just before admission and again during the stay. UHC paid the claim that was submitted. Despite this, one of UHC's external audit companies took back the payment, asserting the inpatient level of care was not medically necessary – basically stating the patient did not need to be admitted to the rehab hospital for care. WakeMed was forced to appeal the decision to receive payment for care that UHC had previously authorized and approved.
• In 2023, a 72-year-old patient required emergent major joint/limb reattachment procedure. UHC initially denied the claim – after the necessary care had been provided – requesting WakeMed provide a more detailed bill. WakeMed obliged and sent the revised information through UHC’s secure electronic portal, as requested. UHC stated they never received the bill. WakeMed resubmitted the bill, as requested. Two years later, WakeMed continues to await payment and has spent countless hours trying to resolve this case.
• A very sick newborn baby was admitted to WakeMed, requiring a 15-day inpatient stay. UHC authorized the hospital stay, and paid the claim when it was submitted. However, after paying the claim, UHC took back their payment, stating they were not the infant’s primary insurer. Thankfully, the patient’s parent, the UHC member, supported our position and provided information that proved UHC was in fact the primary insurer. UHC still refused to repay the claim, stating that WakeMed did not provide the information to challenge their denial in a timely manner. Many hours were spent attempting to resolve this issue and obtain payment for this valid claim.
• A 59-year-old patient was admitted to WakeMed after coming to the emergency room with a severe pancreatic disorder. The patient’s condition required a 32-day hospital stay. UHC approved the admission but denied the submitted claim – requesting an itemized bill. After WakeMed submitted the itemized bill, UHC requested the claim be rebilled as a completely new claim. UHC then denied the re-billed claim, stating WakeMed did not submit it timely. For over a year, WakeMed has requested an explanation on this denial, and UHC has offered no response.

To put the volume of UHC denials in perspective, in October 2025, UHC provided WakeMed with a denials report covering a recent 12-month period. This report showed they denied 21,000 – or 10% – of claims submitted by WakeMed hospitals and physicians in similar scenarios as those outlined above. The denied claims totaled $106 million, which resulted in over $35 million in contracted payments being lost by WakeMed. UHC offered no apologies for this. To try and reclaim payment for the care we provided, WakeMed has dedicated significant time and resources to submit, re-submit, appeal and fight UHC’s denials – resources that are costly and would be better used supporting our patients in other ways.

Our goal in sharing this information is to illustrate to our community how widespread and impactful these issues with UHC are. WakeMed is not alone in facing these challenges. We believe our patients – UHC members – have a right to understand the many ways UHC is putting profits over patient care. We will continue to publish more data on our issues with UHC to ensure the community is aware of this challenging situation.

As a not-for-profit, WakeMed is committed to serving our community – regardless of their ability to pay. We reinvest our earnings into our community by expanding services and access. Reasonable agreements with health insurance companies are essential to our continued ability to provide care to all.

Unfortunately, as we have been in this situation for several years now, WakeMed is faced with two choices: force a resolution with UHC or not recontract with them, thereby permanently ending the relationship.

Our patients are the center of all we do and restoring your in-network access to care is the sole reason we continue to meet with UHC. At the same time, WakeMed feels strongly that UHC's focus is not on improving health or ensuring quality. Instead, they have shown repeatedly that it benefits them more to deny medical care provided than to abide by our contract. In order to continue providing care for all members of our community, WakeMed must take a stand against for-profit insurance companies who are artificially managing cost by denying payment.

What We are Asking For

Throughout our negotiations, we have been focused on is about making sure that our patients get the benefits you are entitled to and that your care decisions are based on medical need—not corporate profit. 

We’re asking UnitedHealthcare to agree to a contract that:

• Protects your relationship with your WakeMed physician
• Ensures access to medically necessary care
• Requires UnitedHealthcare to honor the terms of our agreement

Resolving these issues remains our priority and focus and has – to this point – precluded us from evaluating any comprehensive contract proposal. UnitedHealthcare’s most recent proposal offered no measurable increase in reimbursement rates for the next four years – despite expected increases in labor, supply and equipment costs.

Since 2016, hospital operating costs have climbed nearly 36 percent nationwide – and these trends continue. As a UnitedHealthcare employer and member, your costs for coverage have likely increased in recent years as well.

During the past nine years, our reimbursement rates with UnitedHealthcare have increased very modestly, and far below our cost increases. As a result, WakeMed is currently being reimbursed by UnitedHealthcare at 2019 levels, while WakeMed is paying 2025 costs for wages, supplies, pharmaceuticals, etc. Again, what they are charging you and your employer have certainly kept pace – and those additional revenues coupled with denials of medically necessary services are driving UnitedHealthcare’s record profit margins.

UnitedHealthcare’s own publicly available hospital rate data highlights the significant differences between WakeMed’s payment rates for inpatient and outpatient services and what other Triangle-area health systems are paid for the same services.

This means that since WakeMed and UnitedHealthcare were unable to reach a commercial agreement by November 15, 2025, employers and individuals will pay much more for care that will be directed away from WakeMed to other, higher-cost health systems in the Triangle area.

In the most recent proposal WakeMed sent to UnitedHealthcare, we asked for reimbursement recoveries related to inappropriate denials for services provided – essentially for certain policies that add no value to the patient and increase our costs to comply be ‘turned off.’

We also asked for rate adjustments based on the Bureau of Labor Statistics’ Consumer Price Index (CPI), an independently calculated measure of cost inflation, specifically applicable to hospital and physician costs. Using a CPI-based factor is reasonable and verifiable and will avoid protracted future negotiations that only disrupt our patient’s access to care.

The combination of reducing denials of medically necessary services that WakeMed has already provided, and CPI based rate adjustments, is a very reasonable request that will continue to position WakeMed as the low-cost health system in the area.

How You Can Help

If you want to continue receiving in-network care from WakeMed, help us negotiate on your behalf by:

• Calling UnitedHealthcare at the number on the back of your health insurance card. Ask UnitedHealthcare to reach a new agreement that maintains your in-network access to WakeMed and protects the relationship you have with your physician.
• If you have employer-sponsored health insurance, talking to your employer or HR representative about your desire to have continued access to WakeMed’s high-quality caregivers and services. You can also suggest your employer call WakeMed’s Managed Care Department at 919-350-7983.

We will continue to keep you updated on our negotiation progress. Rest assured; we are working hard to resolve this issue as we want to continue being able to serve your health care needs.

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