Emergency regs issued in CA to address network inadequacies

 - Dave Jones

California Insurance Commissioner Dave Jones has issued emergency regulations to address growing concerns from consumers over the adequacy of insurance company provider networks and the accuracy of provider listings—with implications for radiology.

The insurance commission in California has jurisdiction over PPOs and indemnity health insurers. The Department of Managed Health Care (DMHC) regulates HMOs and has only recently begun addressing similar concerns about network adequacy.

“There have been concerns about the adequacy or the accuracy of the provider networks that these plans are publishing," said Bob Achermann, executive director of the California Radiological Society.  “There are practices that don’t exist, physicians who don’t practice and physicians who don’t accept new patients. A lot of advocacy groups and the two regulatory agencies (the Department of Insurance and the DMHC) have been particularly concerned about what are we selling here, and whether people are being misled about the availability of services and the adequacy of these provider networks.”

According to the Department of Insurance, the new regulations would require insurers to:

  • Include an adequate number of primary care physicians accepting new patients to accommodate recent and ongoing anticipated enrollment growth;
  • Include an adequate number of primary care providers and specialists with admitting and practice privileges at network hospitals;
  • Consider the frequency and type of treatment needed to provide mental health and substance use disorder care when creating the provider network;
  • Adhere to and monitor new appointment wait time standards;
  • Report information about the networks and changes to the networks to the Department of Insurance on an ongoing basis
  • Provide accurate provider network directories to the Department and make them available both to policyholders and the public, so that those shopping for health insurance have this information as well; 
  • Make arrangements to provide out-of-network care at in network prices when there are insufficient in-network care providers.

“I was struck by the breadth of the provider directory requirements, which are much more detailed than what is out there right now,” Achermann said.

A new development that could be potentially be onerous, Achermann said, has to do with a provision that when a patient goes to a hospital for non-emergency services the facility and plan would have to disclose to the insured—prior to getting services—whether there are any non-network hospital-based physicians (like radiologists) in the facility, the likely scope of service they will provided and the costs.

“That could be a real challenge when you don’t know exactly what is going to transpire with that patient,” Achermann said. “How many days are you going to stay? How much imaging are you going to get? So that’s new, and that's something we (the California Radiological Society) is probably going to comment on.”