Why All Roads Lead to Network Adequacy

In recent years, the uneven playing field between the large carriers in Georgia and the rank and file physician practices across the state has become even more skewed toward these payers. More aggressive tactics have littered the physician landscape recently, such as the following:

• The frequent reissuance of physician fee schedules sent as opt out–no negotiation only notifications with small sample fees. Meaning the only option is an objection which is tantamount to termination.
• The use of carrier specific/proprietary CPT code weighting (RBRVS) designed to adjust provider fees with no negotiation or notification.
• The use of narrow network deployments to justify the creation of new sub-HMO networks designed to drive down provider fees via the threat of being left out of network.
• Offering the range of carrier networks as a block, such that, in order to access more favorable lines of business, providers are forced to participate in other networks at lower rates. Similarly, in many cases, the large carriers will not allow the termination of a single network offering without terming the entire agreement which locks providers in to unfavorable networks as well.

A number of coalescing factors have combined to allow for the landscape under which these kind of tactics are now available:

• Among the requirements by the state health benefit plan is to only accept offers from statewide networks. This locks out regional offerings leaving only the largest carriers in the state as available options, thus incrementing their already massive leverage even higher.
• National mergers now leave only 5 major carrier options in the state, 2 of whom have struggled to sell outside of Atlanta, thus increasing the payer blocks of business managed by the top 3.
• Little to no oversight by CMS for Medicare Advantage plan tactics and lack of jurisdiction by the state Department of Insurance over these plans.
• Continued acceptance of egregious tactics by the physician community who have come to expect the next shoe to fall when dealing with the large carriers. As such, organized push back has been limited to the point that it is cited as evidence of acceptance by the carriers on multiple occasions.

In this kind of environment, the obvious initial thought is to fight the good fight at the tactical level. The typical response is to engage each of the individual carrier adjustments to inform providers to educate themselves, formulate individual strategies, and develop grassroots response when necessary to address the barrage of issues. That said, given the seemingly never ending stream spewing from the carriers, it seems timely to stop and consider more sweeping and longer term solutions for providers facing these difficult tactics. In our mind, there are 2 main changes which could be implemented legislatively that would even the playing field and allow providers to protect themselves without having to turn to the governmental agencies for constant support:

1. Loosening the anti-trust requirements which forbid collective bargaining- Currently, carriers use their massive footprint to leverage large chunks of business in their dealings with providers. Meanwhile, the providers, as sellers of a service, are under stringent requirements to individually negotiate, protect rates from sharing, and avoid any sense of collective bargaining unless tough integration requirements have been met. While many groups have reached integrative status, it is a costly and time consuming process to develop and maintain. If federal legislation would allow for less invasive associational type collaboration to perform true collective bargaining, smaller providers without the means to support a clinically integrated operations would immediately have the ability to have their issues heard and negotiations taken seriously. Obviously, that requires federal legislative involvement, which is well beyond our current scope of influence. This brings us to item #2.

2. Implementing true network adequacy guidelines for all products offered in the state (Commercial, Medicaid, Medicare, or Health Exchange)- Nationally accepted guidelines for the adequacy of a network to serve its members have been previously developed by the Association of Insurance Directors. These guidelines have specific requirements of specialty providers, per amount of enrolled population, which could be utilized by Georgia to give teeth to the concept. By deploying specific requirements with real penalties, such as the inability to sell product if not met completely, carriers would be forced to comply with the standards. As an example, Ambetter was able to launch its health exchange product in the Savannah market with less than 5% of the local physicians upon initial go live. Under these new guidelines, carriers would be forced to engage the local providers to build a legitimate network prior to accepting membership. Also, in the instance of ongoing claims issues or reissued fee schedules, if the providers could invoke the threat of termination in a manner that comes with a credible threat of shutting down new sales or eliminating current coverage upon determination of network inadequacy, then there is little question that provider negotiations, renegotiations, fee schedule objections, and claims issue grievances would be dealt with under a more fair platform.

Network adequacy as a solution is only as effective as its oversight, therefore, we believe that we need not only legislation with specific, objective, and enforceable guidelines but also the empowerment of the Department of Insurance to effectively implement any new law. The DOI has been effective as a provider advocate in the past but has been limited in jurisdiction over plans which are anything other than fully insured commercial options. In our mind, their oversight needs to extend to all plans with teeth to enforce at all levels.

In summary, we believe that the landscape has been skewed in the carriers favor for far too long. While it is inappropriate to paint all carriers with the same brush, we do believe that some type of sweeping reset needs to occur to even the playing field. We believe that initial response starts here.