The up 'Hill' battle to preserve Medicare Advantage networks

                brett-coldiron-headshot.jpg
By Academy President Brett Coldiron, MD

In 2013 the AADA learned that insurance companies began to narrow their provider networks in select markets, in many instances without cause. As a result, many dermatologists have been notified — either directly by the health insurer or indirectly by patients — that they are being terminated from one or more of the health insurer’s plans, and many patients are no longer able to access quality care from their preferred physician. 

To tackle this issue, the AADA pursued numerous strategies to persuade UnitedHealthcare (UHC) to stop narrowing its Medicare Advantage (MA) network, including meeting with top UHC officials and writing a joint letter with the AMA asking the Centers for Medicare and Medicaid Services (CMS) to intervene. Once efforts to work with UHC and CMS had been attempted, the AADA joined a group of state and local medical societies in filing an amicus curiae brief supporting a lawsuit against UHC, which successfully delayed its termination of more than 2,000 physicians from UHC’s MA network in Fairfield and Hartford counties in Connecticut. 

Earlier this year, AADA leadership met with the White House and key congressional officials to discuss the issue and relay the specialty’s concerns that narrowed networks will have devastating effects on patient access to quality care. Read a summary of the meeting in the April 2014 edition of Dermatology World.

The AADA also evaluated four MA networks (Boca Raton, Cincinnati, Hartford, and Providence) to determine their network adequacy. The AADA sent CMS a letter detailing our findings that networks were inadequate to CMS standards and made recommendations for modifications. We also requested insurance companies comply with existing regulations and allow physicians an opportunity to appeal their removal from network. Finally, we asked for transparency in the termination process — both for providers, to know why the termination occurred, and for patients, who may have purchased a plan with the assumption about which physicians were still included in their provider network.

Narrowing network issues go beyond UHC’s actions in Connecticut. It is an issue that is spilling over to other states as they seek to reduce premiums and simultaneously reduce patient costs. As the push by insurance companies to narrow their networks has expanded, state legislators, state insurance commissioners, and governors have taken notice and proposed mitigation strategies.

If you have been removed from a provider network, the AADA developed a step-by-step guide on how to respond to the insurance company. While the guide cannot guarantee the cancellation will be revoked, it will provide you with the tools necessary to attempt an appeal.

Some additional efforts that will be undertaken this year include:

  • Conduct additional research of MA network adequacy throughout the country
  • Conduct an environmental scan of health exchange network adequacy
  • Develop a coalition of impacted provider associations and patient advocacy groups

If your state is experiencing a narrowing of network plans or is proposing a mitigation strategy, please contact David Brewster, assistant director, practice advocacy, at DBrewster@aad.org or (202)609-6334.   

Dr. Coldiron, a dermatologist in private practice in Cincinnati, Ohio, is president of the AAD. He is a clinical assistant professor at the University of Cincinnati. Dr. Coldiron is a past chair of the Academy’s health care finance committee. He is a past-president of the American College of Mohs Surgery and a past president of the Ohio Dermatologic Association and the Cincinnati Dermatological Society. In addition, he is a past board member of the American Society for Dermatologic Surgery and the American College of Mohs Surgery. 

Related resources: