Five recommendations to address insurer interference
December 2024—In a white paper released this fall, the CAP sets forth five recommendations to address private health insurers’ interference in patient-physician and physician-physician relationships by limiting the number of in-network physicians or exclusively contracting with particular providers and facilities.
In the paper, “Examining the State of Health Care’s Private Payers and the Adverse Impact of Insurance Interference,” the CAP says “Two-thirds of the country’s population is covered by private health insurance, yet the coverage provided is less and less meaningful.”
Insurers in a highly consolidated market have increasingly used their market power to impose rate cuts and other burdens on pathologists, the CAP says. In addition, issues around the implementation of the federal No Surprises Act “appear to have emboldened insurers” in imposing rate cuts and other burdens on physicians.
“The only real backstop for out-of-network physicians,” the CAP writes, “is the federal independent dispute resolution (IDR) process, yet pathologists have reported significant difficulties in resolving payment disputes due to the burdensome process, high administrative costs, significant backlog/delays, and continuing confusion.”
The CAP identifies four distinct but related categories to illustrate how insurers are interfering with physician services and patient care at the local level. Insurers are 1) relying on narrow/tiered and often inadequate networks of contracted physicians, hospitals, and other providers to shift costs to enrollees; 2) reducing reimbursement and offering unacceptable contracts; 3) using nonstandard coding requirements; and 4) imposing prior authorization and other utilization management measures.
“As we hear from physicians about unacceptable take-it-or-leave-it contracts and/or unworkable new payment terms in contracts from insurance companies,” the CAP writes, “it is clear insurers are moving forward with increasingly narrow and often inadequate networks . . . to the detriment of patient care.”
The health care community should come together to urge adoption of proposals that protect coordinated care delivery in the best interests of patients, not insurers, the CAP says. Its five recommendations are as follows:
- Require adequate networks that include hospital/facility-based physicians. The CAP recommends that state and federal agencies evaluate their approved and licensed insurance plans’ networks for in-network pathologist participation adequacy and the timeliness, proficiency, and scope and use of services.
- Restrict in-network steering/tiering and prohibit economic/cost-only network criteria.
- Maintain physician-led team-based care.
- Include regular monitoring/audits and meaningful enforcement. Requirements must include a mechanism by which providers and enrollees are able to file formal complaints about network adequacy with regulators.
- Increase antitrust scrutiny.
The full paper is at https://bit.ly/CAP_privtpay.