What Is Network Adequacy?
Network adequacy is the ability of a health plan to provide its participants/patients a sufficient number of in-network providers, including primary care and specialty physicians, such as pathologists, as well as other health care services, that are included in the insurance plan for patients.
When a physician participates in a health care network, a patient receiving care from that physician will not receive a balance bill for service(s) provided. Scenarios that create balance billing usually occur as the result of failure in health plan network adequacy at hospitals and facilities where patients cannot access providers within their health plan network.
Read the STATLINE article on how the CMS adopted a CAP advocated requirement for network adequacy.
Why Is the Network Adequacy and Balance Billing Issue Important?
Network adequacy and balance billing influence the market value of pathology services, regardless of whether a pathologist is an employee or an independent contractor. In the best interest of the patient, state regulators should ensure health plans maintain robust networks of physicians to ensure timely access to care for all insured patients. In addition, insurance payers who fail to maintain an adequate network should also be responsible for paying pathologists as out-of-network providers, all billed charges due to insufficient network coverage.
Our Position on Network Adequacy
The CAP advocates for states to require health plans to have adequate networks of hospital-based physicians, including pathologists. We recommend states evaluate their approved and licensed insurance plans’ networks for in-network pathologist participation adequacy as well as the timeliness, proficiency, scope of pathology services provided, including genetic analysis, and utilization of pathology services. We believe that any state-approved health insurance plan network, including qualified health plans under State Health and Federal Insurance Exchanges/Marketplaces, be subject to plan adequacy requirements, enforced by each state.
State Advocacy Efforts
Our state advocacy efforts on network adequacy and out-of-network balance billing are communicated in our weekly STATLINE newsletter.
Read more on these topics from previous STATLINE articles by state.
What We Are Doing for our Members
We are actively advocating for network adequacy of health plans by state regulators to ensure pathologists are participating providers in the plans.