Network adequacy laws are designed to prevent patients from receiving out-of-network anesthesia care at in-network facilities — and receiving surprise bills as a result, according to Anesthesia Business Consultants President and CEO Tony Mira.
Here are five insights:
1. Network adequacy laws require managed health plans to establish provider network standards, including timely access to medical services and a sufficient number of in-network physicians.
2. Insurance companies create narrow physician networks to reduce costs, according to the American Society of Anesthesiologists. This strategy restricts provider choice and creates insurance gaps that lead to balance billing. Forty-six states have adopted network adequacy laws to prevent these gaps.
3. Humana was recently fined $700,000 for failing to contract with a sufficient number of in-network anesthesiologists in Texas, which left some Humana beneficiaries with surprise bills. The insurer allegedly failed to correctly notify state agencies and consumers about existing coverage gaps, in violation of the state's network adequacy law.
4. Network adequacy laws must be strongly enforced to prevent provider exclusion and economic harm, Attorney Marlena Grundy-Dietzway said in Washington Health Care News.
5. ASA is working with states to ensure appropriate network adequacy laws are in place. Mr. Mira encourages practices to consult professional societies and legislative representatives to learn about their state's network adequacy laws.