Network Adequacy/Out-of-network Billing
July 2016 Status Report
Network Adequacy
For the past two years, the Nevada Orthopaedic Society has been engaged with the Nevada State Medical Association and other clinical specialty groups to help resolve language in the Nevada Division of Insurance’s proposed regulation on network adequacy. The regulation was finalized last month and NVOS joined NSMA is a tepid endorsement of the final language as a means of moving forward, so we could focus on preparing for the 2017 legislative session.
Nevada State Medical Association Letter to Commissioner Barbara Richardson
Throughout the regulatory process, the DOI consistently favored language proposed by insurance companies, language that cast physicians in a negative light: “refuse to contract” or “fail to inform the carrier when their panel is full”, etc. They were obviously “heard” more clearly than were physicians. However, the carriers are also not totally satisfied with the final language, which is here
In the process of finalizing the regulation, the Commissioner formed a new advisory council to assist DOI in reviewing standards to determine the adequacy of a network plan. The recently named members are:
Insurance:
Jack Kim – United Healthcare
Todd Lefkowitz – DaVita Healthcare Partners
Pete Sabal – Anthem BCBS
Healthcare Providers:
Howard Barron, MD – Pediatric Gastroenterology & Nutrition Associates (NSMA’s nominee)
Nancy Hook – NV Primary Care Association
Bill WelchNV – Hospital Association
Consumers:
Tracey Green, MD – UNLV School of Medicine
John Packham, PhD – UNR School of Medicine
Trevor Rice – Access to Healthcare Network
Out-of-network
OON bills are a partial flip side of the network adequacy issue. As insurance commissioners across the country approve “skinny” networks, more patients are unaware that having insurance does not equate to having access to care. Even though many more people have insurance coverage for the first time, carriers have not necessarily improved their education programs to teach patients how to access and use their benefits. Some carriers seem eager to shift this responsibility for patient education from themselves to physicians.
Also, as many of the new plans have high deductibles, new purchasers of insurance may not realize that a lower premium comes at a hidden price…and that they will be responsible for significant bills before their policy takes over.
The issues of access, coverage and balance billing are being hotly debated in a number of states. Out of networks bills have been a background drumbeat in the past five legislative sessions in Nevada and were actually front and center in two sessions. With the ACA in full effect and constant rule-making from CMS, the need for NVOS to be vigilant is constant. We are in full collaboration with the state medical association and a number of other clinical associations in assuring that physician – and patient – voices are heard.
Our goal is simple: anticipate and defeat any legislative or regulatory impediments to physicians’ ability to exercise their clinical judgment, provide quality care, and bill for patient services.
NVOS applied for and received an AAOS grant to work on this issue as we approach the 2017 legislative session. We are working to:
- Develop consensus about diverse specialty physicians’ combined approach to the policy challenges
- Devise common language to be used to position the physician perspective (informed by national focus group data shared from the AAOS state government affairs office)
- Coordinate PAC donations among the groups that have support funds to allocate
- Educate legislators and candidates
- Replicate a Texas Medical Association comparative analysis of physician networks at a number of major hospitals; the Texas study indicated that physicians WILL contract if the reimbursements rates are fair and reasonable