Insurers May Cut Out More Physicians: What Are Your Options?

Leigh Page

Disclosures

August 14, 2018

In This Article

'Narrow Networks' Are Slowly Starting to Spread

Now, however, the narrow business proposition—to exclude many physicians and hospitals in favor of a few—is being applied to new products in the broader insurance market. For instance, some insurers are launching plans built on exclusive relationships with large health systems and ACOs. These are limited only to doctors within those organizations.

Are Too Many Doctors Being Excluded?

Howard Chen, MD, a solo ophthalmologist in Goodyear, Arizona, has dealt with several narrow plans in the area and thinks many of them have gotten too narrow. "They seem to be gaming the system by making the network so narrow that it's difficult for patients to get in to see a doctor," he says.

When is a network so narrow that patients are effectively locked out? No federal or state regulator has clearly defined what proportion of physicians a network should have, which is called "network adequacy."

Under this concept, a network should have a sufficient number of physicians to cover its members, and these physicians should be nearby. But how nearby? Acceptable driving distances vary between rural and metropolitan areas. And should specialists be as accessible as primary care physicians?

Patients are sometimes misled by inaccurate plan directories that list physicians who aren't actually in the network, or physicians who won't take any new patients. In a 2014 audit of Anthem's exchange networks by California authorities, 12.5% of listed physicians were not practicing at the listed location and 12.8% were not accepting the plan's members.[7]

Another problem with narrow networks is that patients are often confused about their status, and Chen suspects this is also intentional. "Patients are kind of tricked," he says. "It's not been made clear to them that they can't just see any doctor they want. When they find out they can't come to my office, they're surprised. It happens all the time."

Indeed, patients are confused. A 2015 study found that almost one half of consumers who had just switched to narrow networks were unaware of the network configuration associated with their plan.[8]

"In my opinion, there isn't anything good about narrow networks," Chen says. But he isn't shunning them, because he wants to keep his referral relationships strong. Looking for plans that pay relatively well, he has joined at least five narrow plans.

Chen says he wouldn't have been able to get into narrow networks as a solo specialist, so he gained entry through memberships in an independent physician association and several ACOs.

But he still has problems with these networks. Many of the ophthalmology subspecialists to whom he refers patients are out-of-network. The narrow plans will allow these referrals, but only after a lengthy prior authorization process.

"They make it very hard," he says. "Sometimes they flat-out deny the request." When that happens, he has to get the patient involved, and the request is usually approved.

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