Hold health plans accountable for physician network inadequacies

It is important for health plans to have adequate networks to provide access to in-network physicians and hospitals that meet the care needs of enrollees. But when networks are inadequate, it creates barriers for patients seeking new or continuing care. It also limits the patient’s choice of doctors and facilities.

That’s why regulators use network adequacy standards and other requirements to ensure that health plan subscribers can access in-network care within reasonable intervals and timeframes, according to a report by the AMA Medical Services Council whose recommendations were adopted at the AMA’s 2023 interim meeting.

Regulators must do more to ensure network adequacy so patients have options to access care, said AMA President Jesse M. Ehrenfeld, MD, MPH. The newly adopted policy will help the AMA encourage a multi-layered approach to regulatory oversight that includes meaningful standards, network-wide transparency, parameters for out-of-network care, and effective monitoring and enforcement of existing standards.

According to the AMA council report, physicians and other providers are also affected by network adequacy, and while strong network adequacy standards should encourage health plans to negotiate fairly, inadequate networks can negatively impact physicians’ bargaining power.

The report added that network inadequacies often result in excessive wait times for appointments and overburden many network physicians, contributing to increased burden and potential liability for delayed care.

To address network adequacy and reduce the burden placed on physicians, the AMA House of Delegates adopted a policy supporting the establishment and enforcement of a minimum network adequacy standard that requires all health plans to contract with a sufficient number and types of physicians and other providers, including those for mental health and substance use disorders, so that both scheduled and unscheduled care can be provided without undue travel or delay.

The AMA will also encourage:

  • Development and publication of network adequacy assessment tools that allow patients and employers to compare insurance plans and make informed decisions when enrolling in a plan.
  • Using claims data, audits, mystery shopper programs, complaints, and surveys or interviews with enrollees to monitor and validate provider network availability and wait times, network stability, and provider directory accuracy, and to identify other access or quality issues.

Under the newly adopted policy, the AMA confirms that online physicians who provide in-person and telehealth services may count against health plan and network adequacy requirements on a limited basis when their physical practice does not meet time and distance standards, based on regulatory discretion, such as when there is lack of physicians in the required specialty or subspecialty within the community served by the health plan.

In particular, the policy states, the AMA does not support counting physicians who offer only telehealth services toward network adequacy requirements.

Delegates also voted to support regulations to hold health plans accountable for network inadequacies, including the use of corrective action plans and significant financial penalties.

In addition, the House of Delegates adopted a policy to encourage the use of multiple criteria for evaluating the adequacy of a health plan’s physician network, including:

  • Minimum physician-to-enrollment ratios for all specialties and subspecialties, including those providing mental health and substance use disorder services accepting new patients.
  • Minimum percentage of non-emergency physicians available at night and on weekends.
  • Maximum time and distance standards, including for enrollees who rely on public transportation.
  • A clear standard for online review wait times for all specialties and subspecialties, developed in consultation with the appropriate specialty societies, for both new patients and continuing care, that meet the urgent and non-urgent health needs of patients.
  • Enough physicians to meet the care needs of people experiencing economic or social marginalization, chronic or complex health conditions, disabilities, or limited English proficiency.

In addition, the AMA will support requiring health plans to report annually to regulators and prominently display information about network adequacy so that it is available to enrollees and consumers who purchase plans. This includes:

  • Breadth of the plan provider network, by county and geographic region or metropolitan statistical area.
  • Average wait times for primary and behavioral health care appointments, as well as common specialty and subspecialty referrals.
  • The number of substance use disorder physicians in the network who see new patients in a timely manner and the type of substance use disorder medications offered.
  • The number of in-network psychiatrists and other healthcare professionals who receive new patients in a timely manner.
  • Guidance for consumers and physicians to easily contact regulators to report complaints about inadequate provider networks and other access issues.
  • Number of physicians versus nonphysician providers in the network overall and by specialty and practice focus.
  • The number, geographic location, and medical specialty of all physician contracts terminated or added during the previous calendar year.

In a separate action, delegates addressed any voluntary provider laws that allow physicians to contract with insurance companies to participate as network physicians without discrimination.

Many insurance companies restrict access to their networks for new doctors. This limits the ability of physicians to establish practices and provide care to patients. However, some states have passed voluntary provider laws, which allow doctors to contract with insurance companies, according to a resolution introduced at the Interim Meeting.

The AMA believes that access to quality health care should not be limited by insurance company practices that limit physicians’ ability to establish successful practices, the resolution states.

To that end, the House of Delegates directed the AMA to:

  • Develop and advocate for a model statewide Any Willing Provider Act, enabling all physicians to build successful practices and provide quality patient care.
  • Lobby for federal regulations or legislation requiring insurers to implement any willing provider policy as a prerequisite to participating in federally supported programs.
  • Work with state and national organizations, including insurance companies, to promote and support the adoption of all voluntary provider laws, and will monitor the implementation of these laws to ensure they have a positive impact on access to quality health care.

Read about other highlights from the 2023 AMA Interim Meeting.

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