For thousands of residents in Hawaii, a trip to the doctor is usually a routine matter of scheduling and co-pays. But for members of UHA Health Insurance seeking care at Adventist Health Castle, that routine has recently been disrupted by a confusing contradiction: the insurance provider and the healthcare system are telling patients two different things about who is “in-network.”
The dispute centers on whether the participating provider status extended to Adventist Health Castle applies only to the hospital itself or if it encompasses the broader ecosystem of affiliated clinics and physicians. While UHA maintains that its longstanding contract covers all these entities, Adventist Health Castle has reportedly been informing staff and updating its website to state that its clinics and physicians no longer participate with the plan.
As a physician, I know that this kind of administrative friction is more than just a billing headache; it creates significant anxiety for patients. When a patient is told their doctor is “out-of-network,” the immediate fear is a surge in out-of-pocket costs or a forced disruption in the continuity of care—the steady, long-term relationship between a patient and a provider that is critical for managing chronic conditions.
The Core of the Contractual Dispute
The tension stems from a disagreement over the interpretation of a partnership that has lasted nearly three decades. According to Howard Lee, President and CEO of UHA, the insurance company is operating under a current contract that explicitly includes the hospital, the clinics, and the physicians within its participating provider network.
The crux of UHA’s position is the absence of a formal legal break. In the insurance industry, moving a provider from “participating” to “non-participating” status typically requires a formal termination notice. UHA asserts that no such notice has been received from the Adventist clinics or physicians.
UHA points to a critical piece of evidence: the flow of money. The insurer claims that Adventist Health Castle continues to submit claims to UHA for care provided to members and continues to accept the payments issued under the participating provider contract terms. From UHA’s perspective, the act of billing and accepting payment under the contract constitutes a continuation of the agreement, regardless of what is listed on a website or told to a patient in a waiting room.
Comparing the Conflicting Positions
| Entity | UHA’s Position | Adventist’s Reported Position |
|---|---|---|
| Adventist Hospital | Participating Provider | Participating Provider |
| Affiliated Clinics | Participating Provider | Non-Participating |
| Affiliated Physicians | Participating Provider | Non-Participating |
| Contract Status | Current and Active | Limited to Hospital Only |
The Impact on Patient Continuity of Care
When a healthcare system communicates that its physicians are out-of-network, patients often take immediate action to avoid “surprise billing.” This can lead to patients prematurely switching doctors or delaying necessary screenings and follow-up appointments. In the medical community, we refer to this as a disruption in the continuity of care, which can lead to poorer health outcomes, particularly for those managing complex diseases like diabetes or hypertension.
The confusion is compounded by the “mixed signals” occurring at the point of service. A patient may see a physician who believes they are out-of-network, while the insurance company continues to process the claim as in-network. This creates a volatile environment where the patient is left to guess which party is correct, often fearing that a bill will arrive months later for a balance they weren’t prepared to pay.
UHA has urged Adventist Health Castle to work in the best interests of the community, emphasizing that the primary goal should be ensuring members have uninterrupted access to the care they need.
Navigating the Confusion: Steps for UHA Members
For members currently receiving care at Adventist Health Castle clinics or from its affiliated physicians, the contradictory information can be daunting. To manage this situation, patients should prioritize direct communication with their insurer over anecdotal information received at a clinic front desk.
- Verify via UHA: Before changing providers, members are encouraged to contact UHA Customer Services at (808) 532-4000 or (800) 458-4600 to confirm the current status of their specific provider.
- Document Communications: If a clinic informs a patient that they are out-of-network, the patient should note the date, the name of the staff member, and the specific reason given.
- Review Explanations of Benefits (EOBs): Patients should closely monitor their EOBs from UHA to see if claims are being processed at the participating provider rate.
- Ask About Continuity of Care: If a provider insists they are out-of-network, patients can ask their insurer about “continuity of care” provisions, which sometimes allow patients to keep seeing a provider at in-network rates for a set period during a transition.
Disclaimer: This article is for informational purposes only and does not constitute legal or financial advice regarding insurance contracts or medical billing. Patients should consult with their insurance provider and a licensed professional for specific coverage determinations.
The situation remains fluid, as UHA continues to treat all Adventist entities as participating providers in the absence of a formal termination notice. The next critical checkpoint will be whether Adventist Health Castle issues a formal legal notice of termination for its clinics and physicians or if the two organizations reach a public alignment on their contractual status to clear up member confusion.
Do you have experience with insurance disputes in Hawaii? Share your thoughts in the comments or share this article with others who may be affected.
