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This week’s headline:

Academy action on network adequacy and transparency pays off

After collaboration with the American Academy of Dermatology Association (AADA), Rep. Rosa DeLauro (D-Conn.) and Sens. Sherrod Brown (D-Ohio) and Richard Blumenthal (D-Conn.) have introduced the Medicare Advantage Participant Bill of Rights Act of 2014 (HR 4998/S 2552) that would enhance beneficiary and physician protections, and improve transparency in the Medicare Advantage (MA) networks. Specifically, beginning in plan year 2015, the bill ensures that provider networks cannot be changed mid-year by terminating physicians without cause, and that networks will be finalized before open enrollment begins. The AADA was the first national physician organization to issue letters of support for this legislation.

The AADA also successfully advocated that the following provisions be included in the legislation:

  • Beginning in plan year 2015, an MA organization may only remove a provider from the network if there is cause to remove, such as medical negligence, violation of a legal or contractual requirement, or is unfit to provide services in accordance with requirements of the Social Security Act.
  • MA organizations are prohibited from using cost as a consideration to drop a provider, and the Secretary of the Department of Health and Human Services (HHS) may not consider cost as a favorable factor for a MA organization to drop a provider.
  • Removal from a MA network may only occur after completion of a fair notice and appeal process established by the Secretary of HHS by regulation. The new process established by the Secretary would apply on or after the effective date published in the final rule. Physicians removed prior to a final rule would go through the current appeals process.
  • Nothing in the bill is to be construed as affecting a provider’s ability to decline participation in a network.
  • MA plans must include notification of removal in the annual notice of change for the MA plan for the upcoming plan year.
  • Transparency regarding the measures used by MA organizations to establish or modify provider networks. Plans must provide information on the measures used, including quality and efficiency, the specifications, methodology, and sample size, and other information that the Secretary determines appropriate. This information must be included in the annual bid information and on the website of the plan. The information cannot include individually identifiable information of any provider.

This legislation comes on the heels of the AADA’s meeting with the Centers for Medicare and Medicaid services (CMS) highlighting its 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.

A recent AADA analysis of UnitedHealthcare directories in four cities found numerous deceased, moved and retired physicians. The Medicare Advantage Participant Bill of Rights Act would provide network transparency and require MA plans to finalize their provider networks 60 days before the annual open enrollment period begins, and provide a directory of in-network providers to beneficiaries.

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, by phone at 1-800-MEDICARE through their online form, or by mail to:

Centers for Medicare and Medicaid Services (CMS)
Medicare Beneficiary Contact Center
PO Box 39
Lawrence, KS 66044

Physicians and patients should 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 and encourage them to support the Medicare Advantage Participant Bill of Rights Act of 2014. For a sample letter, contact David Brewster at dbrewster@aad.org.

For more information on the Medicare Advantage Participant Bill of Rights Act of 2014, contact Niva Haynes at nhaynes@aad.org.

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