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Physicians Advocacy Institute

Networking Issues

Networking Issues

The insurance reform and medical loss ratio provisions of the ACA, coupled with pressure to offer affordable plan options to prospective enrollees, have led health plans and entities that organize provider networks to service the plans to turn to other policies to control costs. A powerful cost containment tool that remains within the health plan arsenal is its network of contracted providers. There are few barriers to restrict payers from manipulating their provider network to exclude "high cost” providers, which often means excluding physicians whose patients have serious medical conditions. Notwithstanding the negative impact on access, a consensus is growing that narrow and tiered networks are going to be more prevalent across all health plan products, including Medicare Advantage, health insurance exchanges and employer-sponsored plans.

PAI believes it can play a vital role in helping to identify and address the pitfalls of these suspect networking practices. Through advocacy at the national and state levels, PAI will focus efforts on addressing the following:

  • Inaccurate Provider Directories - A significant barrier to assessing “network adequacy,” and a major concern for physicians and patients alike, is the pervasive problem of inaccuracies in provider directories issued by health plans. PAI will work to promote stronger standards for accurate provider directories at the national and state levels.
  • Inadequate Provider Networks - One way to combat inadequate provider networks is to promote stricter enforcement of “network adequacy” standards. Current regulatory oversight is sparse. The ACA includes general language regarding network adequacy for “qualified health plans” (QHPs), the final rule gives states considerable discretion to enhance these requirements to conform to state law. The National Association of Insurance Commissioners (NAIC) has adopted a model network adequacy regulation, but even in states that have adopted standards, enforcement has been woefully inadequate. The PAI will continue efforts to ensure network adequacy and seek opportunities for proactive advocacy in this area.