Could the Law Be Evolving Toward Granting Medical Providers a "Right" to Be In-Network?

In a Wall Street Journal article on February 6, 2014, it was revealed that many health insurers offered plans in 2014 with limited provider networks. Their business plan appears to have been to exclude from their networks any medical provider that was viewed as expensive, in the eyes of the insurer.

Often, the exclusion of a purportedly “expensive” provider from a network could be because “expensive” means that the care provided is of a higher quality or care provided in a region where the provider (such as a hospital) is the only game in a small town. The ramifications of how the networks are composed — and who is in and who is out — has now touched off both a national debate and a desire for both the federal government and the States to jump into the fray.

Networks were formulated prior to the inception of the Affordable Care Act. The prior motivation of the insurers appeared to have been to expand networks and isolate providers who did not join. This gave the health insurers price control, due to their leverage. But they effectively could not leave out of or deny access to most providers, and they wanted the leverage. Now, the health insurers see an opportunity to “control [their] costs” in a different light, and are leaving out hospitals and other providers, often limiting patients’ choices in a drastic fashion.

Insurance Commissioners, such as Dave Jones in California, are reviewing their network approval procedures, the federal government is considering further regulation, and a bill is being introduced in Pennsylvania. Could this evolve into a situation in which providers gain leverage i.e., they obtain network participation rights? If so, that could have a bearing upon the frequently used threat, by insurers, to expel doctors from a network.

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