Advocacy Council scores a win for a member practice

The Advocacy Council stepped in to help a member whose provider’s agreement was terminated. The member and his entire group of allergists were notified by a major carrier that their provider agreement, for both their commercial and Medicare HMO lines, was being terminated – due to network restructuring. This is an example of a plan narrowing their network.  The Advocacy Council provided advice and support for appealing the decision. Good news - they were successful in their appeal and were recently notified of the carrier’s ruling to overturn its original decision to terminate the provider agreement, and instead, agreed to keep the original policy intact.

Should this happen to you, there are steps you can take:

  • Appeal the decision.
  • Contact the Advocacy Council.
  • We can write letters for you.
  • We can conference with you and the carrier.
  • Contact your state allergy and state medical societies.
  • Contact your legal counsel for advice.
  • Contact local media.
  • Identify patients who could be seriously harmed by their loss to access your services.
  • Address the importance of the patient/allergist relationship.

Narrow provider networks significantly contribute to the surprise billing issue. Although surprise billing may not impact a large percentage of allergists, this issue’s resolution could have ramifications well beyond the specialties (emergency, anesthesia, radiology, pathology) most closely associated with the surprise billing issue. According to the Congressional Budget Office, enactment of language in the proposed surprise billing legislation before Congress (which the Advocacy Council, College and American Medical Association have opposed) would save the federal government nearly $25 billion dollars over 10 years. The bad news is the savings would come largely as a result of lower payments to physicians and hospitals, with a prediction of decreasing payment trends for both out-of-network and in-network providers. So, don’t celebrate a competing practice being forced out-of-network. The end result may be a decrease in payments for both.

There are network adequacy standards for Medicare Advantage plans.  When a Medicare Advantage Organization (MAO) drops providers from their network, it can trigger a network adequacy review.

The Centers for Medicare and Medicaid (CMS) monitor a carrier’s compliance with network access requirements. Each year, CMS, with the support of the network adequacy criteria development contractor, assesses health care industry trends and Medicare Advantage (MA) enrollee health care needs to establish network adequacy criteria. Network adequacy criteria includes provider and facility specialty types that must be available and consistent with CMS number, time, and distance standards.

Access to each specialty type is assessed using quantitative standards based on the local availability of providers to ensure the carriers contract with a sufficient number of providers and facilities to provide health care services without placing undue burden on enrollees trying to obtain covered services. CMS programs the network adequacy criteria into the Health Plan Management System (HPMS) to facilitate an automated review of a carrier’s network adequacy. Sections two and three discuss the established network adequacy criteria.

CMS also provides organizations an opportunity to request exception(s) to the network adequacy criteria and reviews those requests manually. As discussed in section five, valid exceptions to the network adequacy criteria occur where there has been a change to the health care landscape that is not currently reflected in the network adequacy criteria.

You may also reference section 110 of chapter four of the Medicare Managed Care Manual (MMCM) for more information on network access requirements.

Events Triggering CMS Network Reviews

Several events trigger CMS’ review of a carriers’ contracted networks.

  1. Application. Any organization seeking to offer a new contract or to expand the service area of an existing contract must demonstrate compliance with CMS’ network adequacy criteria in its application. Applications are submitted to CMS in February of each calendar year.
  2. Provider-Specific Plan. A provider-specific plan (PSP) is an MA plan designed to offer enrollees benefits through a subset of the overall contracted network in a given service area. An organization requests to offer a PSP with their bid submission on the first Monday in June of each calendar year.
  3. Provider/Facility Contract Termination. When a contract between a MAO and a provider or facility is terminated, CMS may request to review the remaining contracted network ensure the organization’s ongoing compliance with network adequacy criteria.
  4. Change of Ownership. As defined in 42 CFR 422 Subpart L, an MAO change of ownership is the transfer of title, assets, and property to the new owner or acquiring entity that becomes the successor in interest to the current owner’s MA contract. Acquiring entities that have not been approved by CMS to operate in the acquired service area may need to demonstrate compliance with network adequacy criteria through the application process. If required, CMS will provide acquiring entities with the necessary instructions for submitting their contracted network for CMS review. Existing MAOs should reference the change of ownership requirements in chapter 12 of the MMCM for additional information regarding CMS notification requirements.
  5. Network Access Complaints. If CMS receives a complaint from an enrollee, caregiver, or other source that indicates an organization is not providing sufficient access to covered health care services, CMS may elect to review the organization’s contracted network.
  6. Organization-Disclosed Network Deficiency. CMS expects that organizations continuously monitor their networks for compliance with the current network adequacy criteria. CMS encourages organizations to notify CMS upon discovery that their network is out of compliance with network adequacy criteria. Once notified, CMS will request that the organization upload its contracted network for CMS review.

The Advocacy Council and College are working for you – we have you covered.

Advocacy Issue: 
Billing, Coding & Payments
Skinny Networks