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This week’s headline:

AADA raises red flags on adequacy of Medicare Advantage networks with CMS

In a recent meeting with Centers for Medicare and Medicaid services (CMS), leaders from the American Academy of Dermatology Association (AADA) raised grave concerns about the adequacy of the UnitedHealthcare (UHC) and Humana Medicare Advantage (MA) networks and the negative effects these limited networks will have on patient access to care.

Brett Coldiron, MD, president of the AADA, Howard Rogers, MD, advisor to the AADA Private Sector Advocacy Task Force, Ray Welch, MD, and AADA staff specified that these narrowed networks will fail to meet the needs of patients, especially those most in need of care, and urged CMS to reevaluate the adequacy of the UHC MA networks, as well as increase transparency around the current termination criteria and re-examine the appeals process.

A recent history of narrowing networks
In 2013, the AADA learned that several health insurers were narrowing the scope of the provider networks they offer and as a result, many dermatologists were notified — either directly by the health insurer or indirectly by their patients — that they were being terminated from one or more of the health insurer’s products. To date, the AADA and its sister societies have documented 20 states in which either Humana or UnitedHealthcare have terminated physicians to create a narrower network of physicians.

The AADA evaluated four UHC MA networks (Boca Raton, Fla., Cincinnati, Ohio, Hartford, Conn., and Providence, R.I.) to determine the network adequacy and found that — based on Medicare's own definition of network adequacy — UHC MA’s networks have an inadequate number of dermatology specialists and subspecialists, and that the network rosters are replete with errors, making it difficult for MA patients to identify dermatologists participating in their plan, and similarly difficult for dermatologists cut from the network to find participating dermatologists to whom they can transfer their UHC MA patients.

Additionally, the AADA found that the UHC MA physician network terminations were made “without cause,” and failed to provide meaningful appeal opportunities for physicians. The AADA believes that these terminations discriminate against the sickest Medicare beneficiaries because it appears that the primary factor in termination is cost of care provided to patients. The AADA also found that the MA plan sponsors did not provide adequate notice to patients in advance of the open enrollment period that their physician would no longer be a part of the plan’s network. The AADA sent a letter to CMS detailing these findings.

Call to action: CMS needs to hear from your patients
CMS relies on its beneficiaries to file complaints in order to investigate the AADA’s network adequacy concerns. The AADA encourages physicians to inform their patients of the physician’s potential network termination and the impact it could have on the patient’s access to care. Further, the physician should encourage their impacted patients to file a complaint with CMS, through their online form, by phone at 1-800-MEDICARE, and write to their senators and member of Congress to inform them of the impact the termination could have on their access to care through MA.

AADA actions moving forward
The AADA continues to work with CMS to address this critical issue, and has reached out to UHC to discuss the criteria used to terminate a physician and ways to ensure that physicians have a meaningful opportunity to appeal their terminations. Additionally, the AADA will continue to research the MA network adequacy throughout the country, conduct an environmental scan of health exchange network adequacy, and develop a coalition of impacted provider associations and patient advocacy groups. The AADA will provide updates as more information becomes available.

Member guide: responding to network terminations
Physicians who wish to challenge these terminations may need to retain a lawyer for legal advice on their specific cases. Additionally, the AADA developed a step-by-step guide on how to respond. While the guide cannot guarantee the cancellation will be revoked, it will provide members with the tools necessary to attempt an appeal.

For more information, or to report a MA network termination, please contact David Brewster, assistant director, Practice Advocacy, at dbrewster@aad.org or (202) 609-6334.

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