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Playing payor Whac-A-Mole

The fun never ends when it comes to protecting patients from unfair out-of-network charges, per a July 30 Becker’s Review article.

Ever play Whac-A-Mole? It’s a game of strategy, swiftness, and more than a little aggression. You really have to go after those little guys! And right when you think you’ve got one, there’s another right behind. 

You’re probably thinking – wait, did I accidentally sign up for an arcade newsletter? What does this have to do with health insurance? Let us explain. 

It’s no secret that payors are becoming increasingly aggressive, and we take real issue with the fact that their aggression limits access to care. So do regulators, which every so often enact rules or laws that are supposed to keep health plans from just completely dismissing their responsibility to cover services.  

Where it gets tricky–and a bit like Whac-a-Mole–is that if feels like every consumer protection rule is followed by a new sneaky payor practice. How can we keep up?  

Let’s look at a real-life example in North Carolina.  

Payors are supposed to adhere to “network adequacy” regulations, which means that while your health plan can tell you which providers are in or out of network, it can’t use that as an excuse to have zero providers in network. They’re supposed to cover a gamut of services, providers and prescriptions. 

And in the – hopefully rare – case that there just simply isn’t a certain specialist in your plan’s network, due to geography or another reason, you are supposed to be able to go out-of-network at no additional cost. 

Boom, network adequacy. Mole, whacked.

Unless payors decide to just ignore the second part of the rule. 

Humana is under fire for subjecting its North Carolina members to out-of-network costs, while in-network providers were unavailable, and also for also being unwilling to pay for emergency services, according to Becker’s Hospital Review. We’re frustrated, but not surprised.  

We applaud North Carolina for setting the example on how to effectively uphold network adequacy laws. But we also wonder: Are other states doing the same? We don’t have full confidence that this is being enforced for everyone. Are there are instances where insurers aren’t being held accountable for these types of actions?   

Thankfully, Humana has agreed to a settlement and is now reimbursing its members, so here’s to hoping this game of Whac-A-Mole finally ceases. 

Original Article:

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