Q&A on whittling provider networks


Plans are looking to lock in only high value providers

Physicians nationwide are concerned about termination letters from payer partners. Some are going through an appeals process to force the insurer to reconsider. L. William Katz, president, Katz & Associates, Gilbert, Ariz., spoke to MHE to detail the issue.


Q: How will the move by UnitedHealthcare to whittle down provider networks affect other health plans? 

A: Since UHC did not disclose its rationale for these dismissals, I assume it was to restructure its network to include productive, low cost providers.  Physicians excluded are likely to have high maintenance, high cost members on their panels; thus UHC may be hoping that these members will transfer to other Medicare Advantage plans in which their physician is credentialed. 


Q: What actions do other insurers need to take? 

A: Other health plans should prepare for these new members by requiring a screening visit in January to fully document their medical conditions to ensure that they are properly classified for Medicare Advantage payment from CMS.  Assuming they want these new members, in the remaining open enrollment period, other plans should intensify their recruitment efforts in the states where UHC has cut its networks.


Q: Will other insurers follow suit? 

A: Probably not this year.  If they do so, they are likely to do it less dramatically hoping they will draw less attention from the press, insurance commissioners and Congress.


Q: What will be the backlash? 

A: If you are referring to the physician and patient backlash, physicians are unhappy to be classified as “not suitable for UHC’s network” and fear a loss of income with a loss of panel members.  Patients, especially patients with complex medical conditions, are concerned with loss of continuity of care and with the need to build new relationships with UHC approved physicians. 


Q: How will contracting change?

A: In urban areas most physicians are organized into IPAs, ACOs, PHOs, etc. for contracting.  These organizations will attempt to negotiate higher rates or increased performance-related payments and bonuses to counter the rate reduction.  Busy practices, not compelled to accept the new rates by their organization, may opt out of these low payment contracts.  On a positive note, these rate reductions may cause many practices to re-evaluate their use of PAs and CNPs for routine medical matters thereby being able to maintain their financial health without compromising patient care quality.

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