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.
Watch the “Network Adequacy in Health Plans: The Financial Implications for Pathologists” webinar
Read the CAP TODAY Article on Network Adequacy
Read the Advocacy Update 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.
CAP Leads Support of Health Plan Network Adequacy with Multiple Patient Advocacy Groups
The CAP, supported by a number of other health care organizations and patient advocacy groups, is advocating to ensure health plan network adequacy for all patients. In a single public policy declaration, the groups call for state and federal regulators to ensure patients have reasonable and timely access to in-network hospital-based physician specialties – such as pathologists, radiologists and hospitalists – at in-network facilities under any health plan, including qualified health plans approved by the state or federal government.
State Law Requirements for Health Plan Network Adequacy (inclusive of pathology/clinical laboratory services)
Georgia - Code § 33-20E-24
Louisiana - R.S. § 22:1019.1 and R.S. § 22:1019.2
New Hampshire - RSA 420-J:7, II
Tennessee – Section 56-7-2356(a)(2)
Texas – Ins Code § 1301.0055
Virginia - Va. Code Ann. § 32.1-137.2
Washington – RCW 48.49.135
State Advocacy Efforts
Our state advocacy efforts on network adequacy and out-of-network balance billing are communicated in our weekly Advocacy newsletter.
Read more on these topics from previous Advocacy newsletter articles by state.