As provider networks continue to narrow, it is imperative that states reevaluate their network adequacy requirements and the ways in which they safeguard patient access to in-network care.
It is also critical that policymakers ensure transparency in both in-network and out-of-network coverage and require up-to-date and accurate provider directories to help patients make informed health care decisions. The AMA is committed to working with advocates and policymakers to address these vital network issues.
Network adequacy
Provider networks must contain sufficient numbers of contracted physicians and other health care providers in each specialty and geographic region to enable patients to obtain timely access to all necessary medical care from contracted providers. Network adequacy should be determined before a plan is sold to patients and measured using objective standards.
Out-of-network coverage & surprise billing
Information about out-of-network coverage should be conveyed in transparent, simple and accurate terms, and patients must receive fair coverage for their health care needs when they purchase a health insurance product.
Accurate provider directories
Provider directories must be accurate and comprehensive so patients have all the information they need to make important decisions about their health care and health insurance, including whether providers are in-or out-of-network and whether physicians are accepting new patients.
Often though these directories contain inaccurate information about physicians, including their office address, phone numbers and insurance plans they accept.
Previous efforts to improve directory accuracy have been stymied, in part, by a lack of shared understanding and responsibility between clinicians and health plans, a lack of data standards, and fragmented systems to collect and transmit this information. This is exacerbated by already burdensome administrative requirements.
The report, Improving Health Plan Provider Directories: And the Need for Health Plan-Practice Alignment, Automation, and Streamlined Workflows, authored by the American Medical Association and CAOH, analyzes the current state of the provider directory problem, identifies best practices, and recommends practical approaches that both health plans and practices can implement.
Download the report
Issue briefs
Issue brief: Balance billing (PDF)
Other resources
Multi-stakeholder letter on unanticipated (“surprise”) medical bills
Multi-stakeholder letter on NAIC Network Model Act
Georgetown University Health Policy Institute: Defining Narrow Networks — Stakeholders’ Perspective
AMA’s response to Georgetown Narrow Network Research (PDF)
Contact information
For more information on provider network advocacy, contact Emily Carroll, senior legislative attorney, at [email protected].
