To keep premium rates affordable and competitive, health insurers have turned to narrow networks inside and outside of insurance exchanges. They also are partnering with provider groups on accountable care organizations (ACOs), which raises other questions of network size and provider rates. There are various dangers lurking in how provider networks are structured and paid, and carriers are confronting significant legal and public relations problems as a result, especially when they exclude certain providers such as large academic systems or specialty providers. Few issues facing health plans in 2014 are more complex and potentially troublesome. Find out what strategies work best under what circumstances and which are best-suited to your organization.
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Last fall, Seattle Children’s Hospital filed a lawsuit after being excluded by five out of seven insurers offering coverage on Washington state’s insurance exchange. Legal action of this nature — which was recently followed by Connecticut providers — may soon be commonplace nationally. About 70% of insurance plans offered through public exchanges have narrow or “ultra-narrow” networks, according to data from McKinsey & Co., and providers left out of narrow networks are increasingly trying to force their way in through lawsuits, pressure on state regulators or any-willing-provider laws. Beyond the legal and public relations risks they face, carriers will encounter problems if enrollees face mandatory surgeries that need to be performed by providers who are not in the network. Carriers need strategies for not only building these networks, but also for determining how to reimburse out-of-network providers.
Learn what strategies can help you defuse potential provider-network landmines related to narrow networks and ACOs. Discover how different data sources may be used to set out-of-network rates inside and outside of insurance exchanges. And find out how to avoid pitfalls when building networks that exclude costly and/or inefficient providers. You’ll gain valuable insights on these and related issues:
THOMAS BARTRUM is a shareholder at the law firm Baker Donelson and is a member of the firm's health law group. Mr. Bartrum has extensive experience representing a wide variety of health care providers and suppliers of goods and services to the health industry, including hospitals, physicians, physician group practices, nursing homes, home health agencies, rehabilitation agencies, hospices, facilities for the developmentally disabled, independent diagnostic testing facilities, ambulatory surgery centers, rehabilitation therapy providers, management companies, durable medical equipment suppliers and assisted living and personal care homes. He is skilled in matters involving health care mergers and acquisitions, Medicare and Medicaid reimbursement, Medicare and Medicaid fraud and abuse, formulation and implementation of Corporate Compliance Plans, integrated health care delivery systems, provider and practitioner networks and accountable care organizations, and managed care agreements.
WILLIAM J. DEMARCO, MA, CMC, is president and CEO of Pendulum HealthCare Development Corporation and is a leading national expert in the design and development of accountable care organizations. Mr. DeMarco created Pendulum based upon his 40 years of experience in community health plan development and management. He started by working with several health plans in the competitive St. Paul /Minneapolis marketplace. In 1973 he was involved in developing both government health system solutions for Medicaid and Medicare and also worked with large industrial organizations by bringing in early care management methods to help lower costs while improving quality and continuity of care. In 1980, Mr. DeMarco was hired as the lead marketing and development executive during the formation of Clinicare, a locally owned health plan founded by Rockford Clinic Ltd., the largest multispecialty medical group in northern Illinois. In 1984, DeMarco & Associates was formed to assist physicians in optimizing their relationship with private and public purchasers of care, including insurance companies and employers. Mr. DeMarco created Pendulum in 2001, which is a separate but DeMarco & Associates-affiliated company devoted to health data analysis and management of complex infrastructures to support accountable care organizations and pay-for-performance arrangements among employers, payers and providers. His most recent book, Performance Based Medicine, was published in December 2011 and discusses performance metrics and building a high-performance network owned by physicians.
DEBBIE FARRINGER, J.D., is an assistant professor of law at Belmont University College of Law, where she teaches health law courses. Prior that, Dr. Farringer served as senior associate general counsel in the Office of General Counsel at Vanderbilt University, where her practice focused primarily on transactional matters for Vanderbilt University Medical Center, including analysis of contracts for compliance with applicable health care laws such as the Stark law, Antikickback statute, civil monetary penalties law, the False Claims Act, physician practice acquisitions, joint ventures, general corporate governance and corporate maintenance issues, hospital operations, and real estate leasing and purchasing issues. Prior to joining Vanderbilt University, Dr. Farringer was an associate at Bass, Berry & Sims PLC, where she practiced in the firm's Healthcare Industry group. She is a member of the Tennessee Bar, and she graduated summa cum laude from the University of San Diego with a B.A. in History and received her Juris Doctorate from Vanderbilt University School of Law, where she was a member of the Order of the Coif.
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