AMA Wants Insurers Held Accountable for Network Adequacy

AMA policymakers want insurance companies to be held accountable for the accuracy with which they report the size and scope of physician networks they advertise to current and potential subscribers.

At this year’s Interim Meeting of the AMA House of Delegates in Dallas in November, delegates approved a report from the AMA’s Council on Medical Service with recommendations to help ensure that health insurance networks provide “meaningful access” to all medically necessary and emergency care at the preferred, in-network benefit level on a timely basis.

(For other reports and resolutions approved by the House, see the sidebar here.)

The council’s report on “network adequacy” responds to widespread concerns among physicians that many insurance companies advertise physician networks that do not accurately reflect the number of physicians and diversity of specialists actually available to provide services to patients. At the AMA’s Annual Meeting last June, this issue was the subject of resolutions sponsored by several groups, including the Section Council on Psychiatry.

“It’s a hot topic and an area of major concern to physicians and patients,” John McIntyre, M.D., told Psychiatric News. McIntyre is chair of the Council on Medical Service. “The basic problem is that many insurers, in an attempt to hold down costs, employ very narrow or shallow networks that are really inadequate to provide medically necessary care. But patients don’t know that when they sign up because the plan has listed physicians in its provider network who aren’t actually available to provide care. In some cases, the listed physicians are retired, moved out of the area, or even deceased.”

McIntyre, a former president of APA, emphasized that the recommendations from the report have already been put to use in a November 16 letter from the AMA to members of the National Association of Insurance Commissioners, which is revising its 1996 Managed Care Plan Network Adequacy Act. The letter, signed by 115 medical groups including APA, makes the following recommendations:

• Provider networks must include a full range of primary, specialty, and subspecialty practitioners for children and adults to ensure that consumers have access to all covered services, at every level of complexity, without administrative or cost barriers.

• Regulators must review and monitor all networks using appropriate quantitative and other measurable standards.

• Appeals processes must be fair, timely, transparent, and rarely needed. Appeals and other out-of-network arrangements must not be used as an alternative to an adequate network for covered services.

• The use of tiered provider networks and formularies must be regulated to ensure that consumers have access to all covered services, including specialty services, without additional cost sharing or administrative burdens.

• Insurers must be transparent in provider selection standards.

• Provider directories must be accurate, up-to-date, and easily accessible.

The letter points out, “The impact of inaccurate provider directories on consumers can be devastating, especially on those consumers who need to carefully examine networks for specific subspecialists, cancer centers, or children’s hospitals.” It emphasizes that “transparency in directories and up-to-date information on providers is not a substitute for a robust network that allows access to all covered services for both children and adults. Rather, transparent and accurate consumer information should be used as a means to educate consumers about the full scope and limits of a provider network so they have meaningful access to the care they need when they need it.”

Excerpts of specific recommendations in the council report approved at the November AMA meeting include the following:

• Require that provider terminations without cause be done prior to the enrollment period, thereby allowing enrollees to have continued access throughout the coverage year to the network they relied upon when purchasing the product. Physicians may be added to the network at any time.

• Advocate for regulation and legislation to require that out-of-network expenses count toward a participant’s annual deductibles and out-of-pocket maximums when a patient is enrolled in a plan with out-of-network benefits or forced to go out-of-network due to network inadequacies.

• Support fair and equitable compensation to out-of- network providers in the event that a provider network is deemed inadequate by the health plan or appropriate regulatory authorities.

• Support development of a mechanism by which health insurance enrollees are able to file formal complaints about network adequacy with appropriate regulatory authorities.

• Advocate for legislation that prohibits health insurers from falsely advertising that enrollees in their plans have access to physicians of their choosing if the health insurer’s network is limited.

The report on network adequacy also includes a recommendation reaffirming AMA policy that outlines requirements that must be met prior to initiation of actions leading to termination or nonrenewal of a physician’s participation contract, as well as requirements for a meaningful appeals process for physicians whose health insurance contract is terminated or not renewed.

“Given the importance of this issue, the Council on Medical Service will be tracking this issue and may come back with another report if these recommendations are not substantially implemented by the insurance industry,” McIntyre told Psychiatric News. ■