Regulators must require health plans to maintain adequate networks of hospital-based physicians to protect patients from high medical bills.
WASHINGTON, DC — Hospital-based physicians urged quality improvement organizations to protect patients from high medical bills by setting oversight standards to ensure health plans maintain adequate numbers of in-network providers at hospitals.
The College of American Pathologists (CAP) and American College of Radiology (ACR) have called on URAC and National Committee for Quality Assurance (NCQA) to take specific public policy actions on health plan network adequacy. These actions, detailed in letters sent to URAC and NCQA on October 9, include following network adequacy standards set in American Medical Association policy, state regulatory requirements found in the National Association of Insurance Commissioners Health Benefit Plan Network Access and Adequacy Model Act, the Federal Qualified Health Plan Application Standard, and state laws and regulation in California, Louisiana, and New Hampshire.
Tougher safeguards are needed to protect patients from the narrowing of networks of hospital-based physicians practicing at in-network hospitals. Research by Avalere for the Physicians for Fair Coverage in July 2018 quantified deficiencies in health plan network adequacy. Health care policy researchers found:
- 68% of health care plans in the exchange market offered restrictive networks in 2017 (compared to 48% in 2014).
- Nearly 41% of silver plan physician networks in 2015 were defined as small or extra small.
- Insurance plans offered in exchange markets in 2017 covered between 34% to 66% fewer providers than plans available in other markets.
- In 2015, nearly 15% of insurance plans in exchange markets were “specialist-deficient” lacking any in-network provider for at least one specialty, like radiologists.
“As should be noted, states now recognize the need to review and assess this important aspect of network adequacy as part of their routine state oversight responsibility of health plan adequacy,” the CAP and ACR said. “Specifically, we are not aware of any URAC or NCQA standard to assess health plans for hospital-based physician network adequacy or to require that plans meet any standard germane to this issue. Accordingly, in concert with the actions at the state level now being undertaken and given the critical importance of this issue to seamless, transparent and economically efficient health care delivery, on behalf of the physician and patient community, we urge adoption of URAC and NCQA standards in this area.”
About the College of American Pathologists
As the world's largest organization of board-certified pathologists and leading provider of laboratory accreditation and proficiency testing programs, the College of American Pathologists (CAP) serves patients, pathologists, and the public by fostering and advocating excellence in the practice of pathology and laboratory medicine worldwide. For more information, read the CAP Annual Report at cap.org.