Hartford Business Journal

www.HartfordBusiness.com February 6, 2017 • Hartford Business Journal 3 Continued CT expands scrutiny of health plans By Matt Pilon mpilon@HartfordBusiness.com C onnecticut is taking a significant step to improve transparency of insurers' medical provider networks, a move doctors and regulators say is necessary as consumers face more complexities in where they can choose to receive care. A new set of wide-ranging regulations give state regulators the power to determine wheth- er or not a commercial health plan's network of medical providers offers consumers adequate access to health services. The state Insurance Department also will assess for the first time ever the accuracy of insurers' published physician directories. The rules address longstanding sources of friction between doctors and insurers. Doctors say there is a need for greater trans- parency over network adequacy, especial- ly as health plans increasingly adopt "tiered" networks, which incentivize patients to visit certain medical providers over others. Doctors have been skeptical of the tiered approach, arguing they don't always under- stand why an insurer places them in one tier instead of another (Connecticut's new law requires an explainer). They also argue that some tiers may not offer an adequate mix of specialists close to patients and who are also taking prompt appointments. Insurers, meanwhile, have said splitting providers into tiers based on perceived value or other metrics has been an effective strat- egy to control healthcare costs by encourag- ing patients to seek care from higher-quality and/or lower-cost providers. "It is important for policymakers to appre- ciate that broad access and affordability don't always go hand in hand and that high quality coverage can be afforded through structured provider networks," the Connecticut Associa- tion of Health Plans said in testimony on the new regulations last year. Insurance Commissioner Katharine Wade said the new regulations, which took years to hash out, represent a compromise between insurers and doctors and align with standards issued in late 2015 by the National Association of Insurance Commissioners (NAIC), of which she is a member. Connecticut is among the first states to adopt the bulk of the NAIC provisions. Insurers in the state have opposed past legislative attempts to regulate network adequacy, but while the new rules increase state oversight, they likely won't do much — at least for now — to stop the spread of tiered networks. "I think this is an area that needs increased focus," Wade said in a recent interview in her Hartford office. "We need to make sure that con- sumers fully understand the products they're buying and that the companies are providing networks that give people adequate access." The effect of the regulations remains to be seen. Doctors say they are watching keenly, wanting to see improvement in directories and whether or not Wade determines if any in-state networks are insufficient. "This, compared to what we had, is a really good additional step forward," said Dr. Jeff Gordon, president of the Connecticut State Medical Society and a practicing oncologist and hematologist with Hartford HealthCare in Waterford. "We're going to see how this actually works. We can talk in a year about the negatives." Wade and her staff — which includes an examiner who specializes in network adequa- cy — are in the process of evaluating detailed reports submitted by nearly 50 health insurers. Wade is now required to annually assess the adequacy of each plan network. It wasn't clear as of press time exactly how long the first round of decisions would take. "We'll be looking at [the reports] and if there's adjustments that need to be made as a result of our review, then we'll be asking companies to do that," Wade said. Wade said she will be paying close atten- tion to behavioral health providers included in plans because Connecticut has a shortage of those practitioners, according to federal data. The reports from insurers were origi- nally due in mid-October, but the Insurance Department asked a number of carriers to submit additional information, which pushed the due date to Jan. 23. Medical Society CEO Matt Katz said he is enthusiastic about the new rules overall and credits Wade's support as key to getting a bill through the legislature last year. But he's dis- appointed that the network reviews were not complete by the law's Jan. 1 effective date. "We still don't know whether or not these plans have adequate networks and what needs to be adjusted as a result," Katz said. "That's a little disconcerting." Directories The new regulations aim to give insurance customers clearer information about their health plans by requiring doctor directories to be updated at least monthly. There will also be periodic audits. The Insurance Department can enforce corrective actions and fines as high as $15,000 per violation. Physician listings must include such infor- mation as speciality, office locations, group and facility affiliations, languages spoken and whether doctors are accepting new patients. Key for doctors who advocated for the rules is a provision that says insurers must indicate which doctors are in specific network tiers. An outdated or inaccurate directory can cause headaches. And it can sometimes cause a patient to seek care from an out-of- network doctor, resulting in higher-than- expected charges, Katz said. 860.871.1111 Toll Free: 800.741.6367 nemsi.com License #'s: E1-104939 • S1-302974 • P1-203519 • F1-10498 • SM1-192 • MC-1134 MECHANICAL • ELECTRICAL • PLUMBING • SHEET METAL • BUILDING AUTOMATION • FACILITIES SERVICES SERVICE SOLUTIONS…ONE SOURCE The company that builds and installs the critical systems in virtually every type of facility is the same company you can rely on to maintain them. For over 50 years, our clients have trusted us to deliver end-to-end facilities solutions, so they can focus on their core business. We are experts in: Facilities Services Preventive Maintenance Programs Onsite Operations & Maintenance Dr. Jeff Gordon, president, Connecticut State Medical Society Matt Katz, CEO, Connecticut State Medical Society Insurance Commissioner Katharine Wade has new authority over health insurer networks, under a law that kicked in Jan. 1 H B J P H O T O | M A T T P I L O N

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