APA and MPS Advocate for Network Adequacy

On August 21, 2017 the MPS sent comments  (comments on proposed network adequacy regulations_) on the proposed new COMAR 31.10.44 Network Adequacy regulations to the Maryland Insurance Administration, noting that the problem of inadequate provider networks is a longstanding concern among our members that has been exacerbated over the years by administrative burdens, contract requirements and low reimbursement rates.

The proposed regulations would implement House Bill 1318 / Senate Bill 929 from the 2016 legislative session.  They would apply to health insurance carriers that use provider panels, requiring them to file an annual access plan that documents how they meet various network sufficiency standards, including distance, appointment wait times, and provider-to-enrollee ratios.  The proposed standards specify different distance maximums based on specialty and urban (10 miles) vs suburban (25 miles) vs rural area (60 miles). (Numbers in parentheses are for psychiatry).  Urgent appointment wait time for psychiatry is proposed as 72 hours and non-urgent as 30 calendar days.  Provider-to-enrollee ratio is proposed as 1:2,000 for mental health and SUD care.  There is a provision that carriers can use to request a waiver from network adequacy for up to a year.

The MPS suggested the definition of “urgent care” for psychiatric issues be revised to be defined as a condition that is likely to deteriorate to an emergency situation within 72 hours.

We pointed out that the proposed travel distance standards apparently inadvertently failed to include a specific substance use disorder (SUD) provider category, although that group was referenced earlier.

We noted a possible conflict in the proposed distance standards with the existing emergency petition regulations, and suggested an additional definition to resolve it.

The MPS brought conflicting language for Psychiatry in the appointment waiting time standards to the MIA’s attention and recommended that all psychiatrists be included in the 10 calendar day wait time for mental health/SUD providers.

Finally, we pointed out that the numbers associated with the wait times and distance calculations that these regulations propose can be easily manipulated by the carriers to show that on paper they comply.  Therefore, we recommended adding two items to the waiver request requirements, including:

  1. A calculation by Provider Type of the ratio of out of network claims to total claims for each CPT code processed for that Provider Type during the preceding year.
  2. All information associated with a carrier’s network adequacy waiver request will be available to the public.

With these additional requirements, carriers will hopefully begin to make every effort to establish provider networks that are adequate for enrollees in practice.

 

 

On February 11, 2015, the APA and the MPS sent a letter (Letter to MD Gov and Insurance Comm re Parity w Attachments) to Governor Hogan and MIA Commissioner Redmer bringing attention to the very serious problem of access to mental health care, and in particular to psychiatrists, in Maryland’s 2014 Qualified Health Plans (“QHPs”) sold through Maryland Health Connection.  It also highlighted the general need to ensure that all health plans meet network adequacy standards.  The current situation results in higher health care costs for Marylanders and patients with untreated mental illnesses. Excerpts from the letter follow:

On January 26, 2015, the Mental Health Association of Maryland published “Access to Psychiatrists in 2014 Qualified Health Plans,” which chronicles a study of the adequacy of the psychiatric networks in Maryland’s four QHPs examining the accuracy of the provider directories and availability of the 1,154 psychiatrists in those directories to see patients within 45 days. The study results are devastating to those with mental illness or substance use disorders.  Specifically,

  • only 43% of the psychiatrists listed could be reached primarily because phone numbers were not working or incorrect, or the physician died, retired or relocated. (page 5)
  • 19% of those who were reached were not actually psychiatrists although they were listed as such. {page 5)
  • Less than 40% of the providers listed accepted the insurance of the company listing them as a participating provider. (page 6)
  • Less than 18% of the psychiatrists listed were taking new outpatients. (page 6)
  • Only 14% of psychiatrists listed and taking on new patients could see the patient in less than 45 days. (page 1)

Health plans have ready access to the claims data to know whether a physician is taking new patients and whether the physician is an active participant in the plan, but there is no evidence that they use their data to assure their network is sufficient to meet the consumer’s needs. Plans can and should run the data on claims filed for each physician listed in their network on a quarterly basis. If a listed physician has not filed a claim in the past quarter, the physician obviously is not taking that insurance. Likewise, a small volume of claims should lead the carrier to question whether the physician is an active participant in the network and fairly included in the carrier’s analysis of network adequacy. For plans that have an out of network benefit, the plan should run out of network claims data; a large volume of out of network claims means there are not sufficient choices in network because most patients would not voluntarily choose to pay out of pocket if the network in the plan was sufficient.

As you know, the state has the authority to require plans to verify the adequacy of their network and plans have the means to do it. APA respectfully requests that you require all exchange plans (indeed we recommend the state should require all insurance plans) on a quarterly basis to verify the adequacy of their network by publicly reporting (a) the number of claims filed by each psychiatrist listed in the network; and (b) publicly reporting the number of psychiatric claims paid on an out of network basis. Plans must then be required to update the network directories and their network adequacy analysis to remove those physicians that are not actively participating.

Appropriate treatment of mental health conditions will ensure overall health of the population and it will decrease the overall cost of medical care. As evidenced in the attached study by Milliman, spending on mental health care actually reduces the overall cost of health care for individuals and for the state.

Accordingly, APA asks that the state of Maryland ensure that: (a) citizens of the state get access to the mental health care for which they have paid, and (b) health insurance carriers are responsible for providing the resources promised to their customers.  APA would like to work with the state of Maryland to make mental health care, an essential health benefit, available to all of its citizens.