Health Plans to Docs: Curb Costs or We'll Kick You Out

Kenneth J. Terry, MA


May 09, 2014

In This Article

What About Insurance Exchange Plans?

Most of the plans offered through the Connecticut insurance exchange also have narrow networks, Katz says. Doctors were asked to opt in or opt out, and many opted out because the plans were offering sub-Medicare rates. But some physicians were forced to participate under all-products clauses that require them to be in all plans offered by a particular insurer. Katz says those clauses were illegally applied to exchange plans because, under state law, the provisions can't cover new plans.

The situation is even worse in Washington State, where nearly 150,000 patients have enrolled in health plans through the state insurance exchange. The Washington insurers, including Premera Blue Cross and Regence Blue Shield, failed to inform physicians of whether they were included in the exchange plans or not.

"There was no discussion with individual providers as to what plans they wanted to be in, or whether they wanted to be in any of them," says Dale Reisner, MD, President of the Washington State Medical Association (WSMA).

Patients can find out whether their doctors are in the networks of particular exchange plans, but they don't always notice which hospitals are included. This has been a particular problem for Reisner's perinatology group, she says. The high-risk obstetricians practice at Swedish Hospital, which delivers more babies than any other hospital in the state does. Although the group is included in three of the eight exchange plans, Swedish came to terms with only one of these plans. The doctors have suggested that product to their patients -- but in some cases, they did so too late.

"In the first week of January, one patient went into labor only to find out that her insurance didn't cover delivery at Swedish where her OB was on staff," notes Reisner. "As a result, she had to be cared for by somebody else at a hospital she knew nothing about."

Primary care physicians have not complained about being excluded from the exchange plans, she notes. But some of the doctors in these plans -- such as those in Connecticut -- gripe that the specialists they refer to are not in their networks.

"If you need to get hold of somebody right away, you may not have collegial interaction and trust, or they may not be available to you to refer your patients to," she points out. "And sometimes the timing is really important."

Reisner cites two other difficulties that the insurers' lack of transparency has created. First, some doctors who were put into exchange plans without their consent found later that their rates were very low. In addition, some of these physicians didn't have the capacity to take on new patients, raising questions about network adequacy.

The state insurance commissioner has proposed new network adequacy standards, she adds. But neither the insurers nor the providers are happy with the criteria, she notes. The physicians say that the standards lack provisions ensuring that they can negotiate with the plans for reasonable reimbursement.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: