Narrow Networks to save money?

Narrow Networks keep premiums down

How do doctors get paid?

Imagine going to your favorite restaurant. You are greeted at the door by the hostess, who seats you and takes your drink order. You order through your favorite waiter, Andrew, who recommends the special of the day: prime rib with a dinner salad and a chocolate torte for dessert.

Soon after, the food is brought out and it is delicious! You have time to enjoy your food. You then receive the bill and pay for your meal, returning to your home satisfied, all your dining needs met. Let’s say, for simplicity’s sake, you paid $75 for this meal: $50 for the steak, $10 for the salad and $15 for the dessert.

A change then occurs in the restaurant industry. A new form of eating out has been adopted. Your favorite restaurant has now contracted with over 30 different ”restaurant insurance companies.”  Read the rest of the article

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Aetna illegally secured contracts with Pennsylvania’s Medicaid program by misrepresenting the number of pediatric providers in its network, according to a federal whistleblower lawsuit unsealed Tuesday.

The insurer benefited from this alleged fraud because the lack of providers limited access to care, saving Aetna money.  ^{Modern Health Care} *

One Union keeps costs and deductibles down, by giving up access to some of their city’s best known, and most expensive, hospitals.  Workers not only kept their insurance premiums under control, they saved so much money that housekeepers saw their hourly pay increase from $16.98 to $23.60 in five years, a 39% jump.

The price problem has been most acute in communities with dominant hospital systems, studies show.

In California, for example, hospitals that were part of Sutter Health and Dignity Health, the state’s largest hospital systems, increased prices almost 50% faster than other hospitals in the state between 2004 and 2013, researchers found.

Massachusetts General and Brigham and Women’s charged two or in some cases even three times as much as other academic medical centers in Boston.

For example, a hip replacement at the Beth Israel Deaconess Medical Center — which, like Massachusetts General and Brigham and Women’s is a teaching hospital for Harvard Medical School — cost $28,359, according to federal data.

Massachusetts General charged $55,362 for the same procedure, and Brigham and Women’s charged $65,073.  ^{LA Times 12.17.2019} *

1. Out-of-network health care doesn’t have to mean out-of-control cost  
2. 2017 Directories are still lousy
   1. Patients scrambling for Network MD’s due to flawed directories Penny Gentieu did not intend to phone 308 physicians in six different insurance plans when she started shopping for 2017 health coverage.  CA Health Line 12.13.2016
3. How narrow are the new lists (See the Provider Finder Page) under Health Care Reform – Covered CA?
4. Is there a difference in the Covered CA list vs if one buys coverage outside – direct from the Insurance Company or an Agent (at no additional charge)?
   1. Officially no, due to mirroring requirements
5. Why do so many MD’s say they accept direct business from an Insurance Company – but not Covered CA?
6. If your MD is not on the list and of course no one was told… is that a Material Provision and would allow one to change to a better list, with a new company under the rules for Special Enrollment?
7. SB 137 effective 1.1.2016 hopefully will make things easier.
8. Does this lawsuit filed against Blue Cross and Does 1-50 show a material violation?
9. What about 2015 lists?  Will the be better? ♦  LA Times 9.29.2014   ♦  No 10.17.2014 CA Health Line   ♦ InsureMeKevin Health Net PPO EPO Comparison    ♦  CA Healthline 12.8.2015 – Fewer PCP’s and Clients having trouble locating them
10. Are consumers showing a preference for narrow networks to save $$$?
11. Out of Network Costs…vary by Insurance Company  Blog InsureMeKevin.com
12. CMS Rule 9929 F leaves Network Adequacy to the States not the Feds. ^{Modern Health Care 4.13.2017 * CMS.Gov 4.13.2017  * Amazonaws.com}
13. View LATEST news articles on Narrow Provider Lists
14. View actual Evidence of Coverage page 14 and check out the definitions and explanations of the role of the PCP Primary Care Physician and IPA Independent Practise Assoc.

“If you’re competing on price and you can’t vary co-payment structure or deductibles, the only thing you can do is try and keep your networks as affordable as possible,” which means eliminating providers unwilling or unable to meet insurers’ cost expectations.  (CA Healthline.org 2.17.2015)

Here’s the letter from a client of ours that prompted today’s 4.18.2014 update to this website:

Dear Steve I was planning to get in touch with you because as sson as I had coverage it sems that I started to need my insurance… I found a great general doctor and all went smooth with him. My test and Xray had a charge and I paid it but my leg specialist first said that he was participating with Blue Shield but later when he discovered that it was Covered California he said he was not and I had to pay his visit and the MRI ( $500) A second  specialist that I contacted to check on my lungs upon suggestion of my GD, called afer I made the reservation to say the same thing and I had to find an other one, Does Blue Shield have two different PPO  one for general public ad one for CC?

***Here’s a screen shot from Blue Shield’s  provider search.  It shows that the MD list for PPO and EPO is the same for 2014 Health Reform Compliant Plans in and out of Covered CA.  More Explanation.I dont’ thing it is fair. What do you know about it? Amelia  – See laws & Regulations on “code” page.

Blue Cross Explanation of Provider Networks – PDF  on this website  Benefit Snapshot – Brochure  In an email dated 4.22.2014 I rec’d confirmation that networks are the same on and off the exchange.

I think it’s a real shame that the “authoritative” answers seem to be Facebook.  Nothing with actual proof or citations.

#MAPD Medicare Advantage

Narrow Networks

Senate bill addresses inaccurate Medicare Advantage directories  AMA.org 

MAPD  customers, are usually restricted to getting care from doctors and organizations included in their plan’s provider network. Most MAPD plans are HMOs, or health maintenance organizations, that have what are called narrow networks – relatively small groups of providers located only in the plan’s home market. ^PBS *

Health Care Dive.com Narrow Networks can cut costs

One  can’t easily or accurately observe plan networks. The surest way to know if a physician is covered by a plan is to scrutinize the contracts between plans and providers. But these are closely held by the organizations, so are unavailable to researchers. Plans do publish provider directories, but there are no validated, comprehensive, historical archives of directories. Those that are available are not uniformly machine readable and are known to contain errors and omissions, such as listing physicians not in networks or failing to list those that are.

“secret shoppers” were able to schedule an appointment with a selected in-network provider in fewer than 30% of cases

on average, Medicare Advantage networks included 46% of all physicians in a county. There is considerable variation by specialty, with psychiatrists being least the likely to be included in plan networks (on average, a plan covered care by 23% of psychiatrists in a county) and ophthalmologists the most likely (59%).   16% of Medicare Advantage plans in 20 counties covered care at less than 30% of hospitals.) As for costs, the October study found that broader-network plans tend to charge higher premiums than narrow-network plans. Jama Network.com *

narrow network plans, insurers that offer these work with a smaller pool of doctors, hospitals, and treatment centers, who agree to a lower price for services with the expectation that they will get greater patient volume.

narrow networks are not strictly defined, the plans often have 25 percent or less of the physicians in the local area participating. The most restrictive plans have less than 10 percent of local doctors signed on.

One in 10 insured Americans say that within the past two years, they have been surprised to find that a doctor, lab, or facility that they thought was in their provider’s network actually wasn’t,

Identifying a plan as a narrow network can be very difficult.

Outdated directories are a problem

Even if you do everything you can to stay in network, sometimes needing out-of-network care is unavoidable, so you’ll want to take a close look at your out-of-network coverage. Some insurers will cover a portion of the cost of seeing a doctor who doesn’t take your insurance.

But an increasing number of plans have no out-of-network coverage at all.  Consumer Reports *

KFF.org MAPD Robust Networks???

Urban.org Why MAPD plans have narrow networks

Blue Cross Removes UC Hospitals From EPO Health Plans

UC Davis Medical Center, UC San Francisco Medical Center and Children’s Hospital, along with Benioff Children’s Hospital in Oakland are no longer part of their Pathway EPO network as January 1, 2022  Learn More – Insure Me Kevin.com

• What are #Mirror ed Plans
  • Mirrored means that  plan benefits and provider networks  must be exactly the same direct and with what is offered in Covered CA. ^{(SB 639 * Cahba.com * Crosby  * 2.7.2014 Email to Cedars Sinai  *}  
    • That is Any Insurance Company  that offers a product on Covered California must also offer a “mirror” plan with identical benefits and networks. The ID cards of all consumers who purchased plans through Covered California display the logos of their respective health plan AND the logo of Covered California. The ID cards of patients who purchased mirror products do not display the Covered CA logo  ^{ACPonline.org} *  Exception to the rule on rates for Silver Plans, “Silver Loading” due to Supreme Court decision.
  • More liberal Provider Networks are a big advantage to Grandfathered Plans
• Is there any difference in #practise the Provider Directory for the same plan be it direct with the Insurance Company or Covered CA?
  • Briefly, NO!!!  That’s what the law says.  See above on Mirrored Plans.

§156.235 Essential community providers.

Link to an amendment published at 80 FR 10873, Feb. 27, 2015.

(a) General requirement.

(1) A QHP issuer must have a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the QHP’s service area, in accordance with the Exchange’s network adequacy standards.

(2) A QHP issuer that provides a majority of covered professional services through physicians employed by the issuer or through a single contracted medical group may instead comply with the alternate standard described in paragraph (b) of this section.

(3) Nothing in this requirement shall be construed to require any QHP to provide coverage for any specific medical procedure provided by the essential community provider.

(b) Alternate standard. A QHP issuer described in paragraph (a)(2) of this section must have a sufficient number and geographic distribution of employed providers and hospital facilities, or providers of its contracted medical group and hospital facilities to ensure reasonable and timely access for low-income, medically underserved individuals in the QHP’s service area, in accordance with the Exchange’s network adequacy standards.

(c) Definition. Essential community providers are providers that serve predominantly low-income, medically underserved individuals, including providers that meet the criteria of paragraph (c)(1) or (2) of this section, and providers that met the criteria under paragraph (c)(1) or (2) of this section on the publication date of this regulation unless the provider lost its status under paragraph (c)(1) or (2) of this section thereafter as a result of violating Federal law:

(1) Health care providers defined in section 340B(a)(4) of the PHS Act; and

(2) Providers described in section 1927(c)(1)(D)(i)(IV) of the Act as set forth by section 221 of Public Law 111-8.

(d) Payment rates. Nothing in paragraph (a) of this section shall be construed to require a QHP issuer to contract with an essential community provider if such provider refuses to accept the generally applicable payment rates of such issuer.

(e) Payment of federally-qualified health centers. If an item or service covered by a QHP is provided by a federally-qualified health center (as defined in section 1905(l)(2)(B) of the Act) to an enrollee of a QHP, the QHP issuer must pay the federally-qualified health center for the item or service an amount that is not less than the amount of payment that would have been paid to the center under section 1902(bb) of the Act for such item or service. Nothing in this paragraph (e) would preclude a QHP issuer and federally-qualified health center from mutually agreeing upon payment rates other than those that would have been paid to the center under section 1902(bb) of the Act, as long as such mutually agreed upon rates are at least equal to the generally applicable payment rates of the issuer indicated in paragraph (d) of this section.

New rules for Federal Exchanges about “Narrow” networks.

Plans generally would have to contract with at least 30% of essential community providers in their market, including community health centers, HIV/AIDS clinics, and children’s hospitals.

Rules PDF
modernhealthcare.com

Article
modernhealthcare.com/

Class Action Felser Lawsuit against Blue Cross

• Felser Settlement 5.5.2016
• Specifically, the lawsuit alleges that Anthem:
  • Delayed giving its customers complete information until it was too late for them to switch their coverage choice;
  • •Did not inform its customers that it no longer offered out-of-network coverage in four of state’s largest counties — Los Angeles, Orange, San Diego and San Francisco; and
  • •Misled or did not inform its customers about which doctors and hospitals were participating in the insurer’s new plans.   “intentionally misrepresented and concealed the limitations of their plans because it wanted a big market share.”

As a result of those alleged failures, the lawsuit states that many members received thousands of dollars in unexpected medical bills and were unable to see their preferred physician. (californiahealthline.org)

55 page complaint – brief (with my personal ONLY opinions, links and research)

Michael Bidart and his firm represented me in a bad faith claim against my home owners insurer some 13 years ago. As a lawyer myself, I can tell you that they are top notch in the field.    Jay  Gov. Jerry Brown (D) has signed a bill (SB 964) to increase oversight of insurers’ provider networks, the Sacramento Business Journal reports (Robertson, Sacramento Business Journal, 10/2). bizjournals.com/ Consumer Watchdog – files against CIGNA & Blue Shield californiahealthline.org/ 2nd Lawsuit latimes.com/

News Briefs 

HHS ruling to urge insurers to be liberal in Provider Lists and Premium Payment Date (CA HealthLine) actual regulation & will coverage really start 1.1.2014   Right to change plans if Provider Finder doesn’t work – Special Enrollment???

Nationally 1/2 of exchange programs have narrow networks modern health care.com

Covered CA urges insurers to expand network  california health line.org

12.12.2013 Covered CA claims 80% of CA MD’s are in their networks 10.15.2013 Covered CA apologies for releasing inaccurate provider list too early.

AIS Health Explanation  Los Angeles Times 9.15.2013 on “Narrow Networks” to keep costs down on plans in Covered CA.   Video about what networks are.  Notice in MD office, not a provider.    Blue Shield of California has said it will include just 50% of the physicians and 75% of the hospitals in 2014 that it did in this year’s individual plans.  However, Blue Shield has said it will offer exclusive provider organization plans — or EPOs — to first-time buyers for a lower cost than other plans on the exchange  ^{CA HealthLine.org   NPR}

Kevin Knauss Post on if there are fewer MD’s in Covered CA then out of Covered CA? Confusing Provider Finders insuremekevin.com

For more information – View the Comments Section of the Provider Finder Page

Myth of MD Shortage – Modern Health Care.com 11.11.2013

Covered CA Contract with Insurance Companies – Provider List Requirements… See Page 9, et seq.

2.23.2014 A Sonora mechanic is in so much pain that he can barely walk, but he can’t seem to find a doctor to fix his ailing back after he and his wife switched their insurance coverage through Covered California. Chris Dunn reached out to CBS13 hoping we could get answers. He needs his surgery yesterday. But instead of scheduling his date, he and his wife are navigating a confusing maze of doctors and insurance plans. sacramento.cbslocal.com/ 2.23.2014 San Jose Mercury News Lowering costs by forcing doctors and insurers to compete for millions of new patients is a primary goal of the nation’s new health care law, but a group of gastroenterologists in the East Bay and internists near Chico are exposing a fissure in that plan. mercurynews.com/