Protecting Patients Against Narrow Provider Networks

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November 13th, 2014

Narrow Provider NetworksNarrow provider networks – which allow insurance companies to keep premiums down by including physicians they see as providing less-costly, more value-based care – are not a new phenomenon. However, after the passing of the PPACA and almost a year of the new health law being in place, narrow networks seem to be disgruntling a few of healthcare’s key stakeholders – patients & providers.

Healthcare reform is now being labeled the break in the damn that has allowed insurers and payers to accelerate the move to narrow provider networks. Many patient and provider advocates have voiced their concern over the issue as it counters both the legislation and purpose of the new health law. One of the key organizations backing the push against insurers is the American Medical Association (AMA). The AMA hopes to initiate action by passing further legislation protecting patients against the financial and medical implications of being shifted into a narrow provider network.ME_page_21

The AMA & Narrow Provider Networks

“While plans with narrow networks may have lower patient premiums, some narrow provider networks on the market today provide inadequate access to timely, convenient, quality care,” said AMA President Robert M. Wah. “Inadequate networks could prevent patients from being able to see the physicians that they know, trust and depend upon throughout their lives which could lead to interruptions in care, delayed care and undue harm. They can also prevent patients who are newly insured from being able to access the physicians that suit their needs in a timely manner. As enrollment opens for health insurance exchanges, patients deserve to have an honest look at their coverage options – including the physicians, hospitals and medications they will have access to as well as cost-sharing so that they can make an informed choice.”

With this in mind, the new policy primarily addresses the issue of inadequate insurance networks and promotes patient financial protections. The AMA calls for insurers to make any provider termination without cause prior to enrollment so patients can select health plans that will cover care provided by their existing physicians. Today, inaccurate or late revised provider directories are leaving patients stuck with plans that have dropped their physicians after they enrolled. Furthermore, the new policy includes an “any willing provider” provision which allows for new physicians to be added to a network at any time.

The move against narrow networks only reiterates the need for insurers to provide more transparent and accurate information to both patients and providers. This allows patients to see the value of the plan they would like to purchase prior to enrolling.

Dr. Wah continued, “If patients find themselves in networks that are deemed inadequate, there should be adequate financial protection in place to ensure they can access the care they need and deserve.”

The proposed policy includes further regulatory protections for both physicians and patients such as:

  1. Treating patient visits to out-of-network physicians the same as they would in-network physicians if the patient’s plan is deemed inadequate.

  2. Regulation and legislation to require out-of-network expenses to count towards a participant’s annual deductibles and out-of-pocket maximums when a patient is enrolled in a plan with out-of-network benefits or is forced to go out-of-network based on network inadequacies.

  3. The development of a mechanism for patients to file formal complaints about network adequacy with regulators.

  4. State regulators as the primary enforcer of network adequacy requirements to ensure state network adequacy laws and regulations are followed and patients have access to adequate provider networks throughout the plan year.

  5. Quarterly reporting to state regulators that is also publicly available to provide data on several measures of network adequacy, including the number and types of physicians that have joined or left the network, data that indicates the provision of Essential Health Benefits and consumer complaints received.

Insurers & payers have rebutted the claims that companies are targeting high-cost markets and eliminating the providers service these patients by stating that narrow networks help keep premiums lower in the federal and state health insurance exchanges.

Regardless of the reason, the AMA and other patient or provider advocates have made it clear that insurance companies must balance the needs and wants of physicians and patients against their widespread mandate to tamp down costs.

One Comment

  • Whereas these narrow networks are discussed more publicly, this is not a new phenomenon. Newly enrolling in Medicare, I chose an HMO with good credentials and with specialized programs for their older patients. Within weeks, I was on the hunt for a breast cancer oncologist--who did not exist in the network. The closest was a man whose specialty was prostate cancer and non-Hodgkins lymphoma, though his PA assured me he "did all kinds of cancer". The surgeon who was to perform a mastectomy touted his own skills at abdominal and vascular surgery. The first could not answer questions about breast cancer, had not retrieved my biopsy from their internal system, yet was the only choice for me in that system. Happily, I could return to Medicare proper, where I had far more choices, and selected a doctor whose entire practice was breast cancer, and who coordinated care with a plastic surgeon who specialized in mastectomies and reconstructions.
    Until patients understand their diseases and their options, and are able to take the most educated and informed role possible in their own care, we will not have the health outcomes which are truly possible in the US.