How to navigate narrow provider networks

Optometrists are feeling the effects of tighter provider networks arising from the Affordable Care Act's (ACA) new health insurance marketplaces.

In Colorado, for example, several large commercial payers have taken steps to limit their provider networks, said Jason Ortman, O.D. As a result, "there have been optometrists who have been shut out or denied the ability to access networks," said Dr. Ortman. He practices in Denver and is a member of the AOA Third Party Center (TPC) Executive Committee.

There have been optometrists who have been shut out or denied the ability to access networks.

"This is a trend that's happening in other parts of the country as well," he said. As recently highlighted in an AOA webinar, insurers are creating smaller networks to better manage costs and offer more competitive products.

Health plans often rely on clinical outcomes and quality care measures to determine which providers yield the lowest cost of care, Dr. Ortman said. Specifically, they look for providers who submit a healthy amount of claims. Those who send the fewest "would probably be the first ones to be removed from the network," he said.

Dr. Ortman said there are ways for optometrists to increase their visibility and ensure their place in a network. Start by submitting appropriate claims to medical insurance plans when possible—instead of just routinely submitting to vision plans.

He said doing so not only will increase the number of claims, but it also will demonstrate the scope of practice and optometrists' role in primary eye care.

Verify your participation in plans

Because of the new exchanges, Dr. Ortman advised optometrists and their staff to verify participation status in specific plans with every insurer in their state.

In some states, confusion has run high. For example, optometrists with an existing contract with a company might assume they'll be grandfathered into any plan that company offers on an exchange, said Mark Lee, O.D.

"This may not be the case due to a narrowed exchange network," said Dr. Lee, a member of the AOA TPC Executive Committee who practices in Las Vegas.

Dr. Lee advised optometrists to talk to the third party center in their respective states for clarity.

In the meantime, the AOA's State Government Relations Committee has been reviewing the issue of narrow networks "and many other discriminatory practices that have popped up recently in the optometric community," said Brian Reuwer, the AOA's associate director of State Government Relations. Reuwer said the committee expects recommendations soon.

Dispute continues on Medicare Advantage plans

Some providers have challenged the practice of narrowing networks. In Connecticut, several medical associations filed a lawsuit against UnitedHealthcare alleging the carrier violated its provider contract by reducing its Medicare Advantage (MA) network by more than 2,000 physicians. The company has taken recent action to narrow MA networks in a number of states.

In early December, a federal judge sided with the associations, issuing a temporary order that prohibits UnitedHealthcare from dropping physicians enrolled in its Connecticut MA program.

UnitedHealthcare plans to appeal the ruling. "As we fully comply with the order in place, we remain focused on serving our members and will continue to provide them with a broad and comprehensive choice of doctors," said Jessica Pappas, company spokesperson for UnitedHealthcare.

Many health plans have made network changes "in the interest of improving quality and affordability of health care coverage for their members," Pappas said. "We believe a tighter and more focused network will improve our ability to collaborate more closely with physicians."

January 15, 2014

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