The Texas Department of Insurance fined Humana $700,000 in 2018 for network inadequacies caused by an insufficient number of anesthesiologists in two counties. The loss of revenue combined with the negative press are a thorn in the side of any health insurer who must juggle keeping up with the network adequacy standards that can vary widely by state.

What constitutes an adequate network?

In general terms, health insurers meet network adequacy standards when plan enrollees have timely access to a sufficient number of in-network providers and other health care services that may be stipulated by state regulations. Timely access can take into account appointment waiting times and even hours of service availability to patients.

Keeping up with changing standards and maintaining a healthy network status is a full time job. We know because we’ve been helping insurers for more than a decade to quickly resolve network inadequacy issues to minimize revenue fallout from compounding fines.

How can an insurer know if their network is at risk of violating network adequacy

A combination of outdated network provider system management on top of the litany of regulatory requirements can make it difficult for plan providers to efficiently inventory and assess the health of their network.

As any health care provider would attest, an ounce of prevention is worth a pound of cure. TOG Network Solutions specializes in network analysis and development to assure our clients avoid costly network adequacy fines and the unwelcome public scrutiny that can follow such actions.

Our approach includes ensuring the provider network maximizes its reach. This is especially important as the pandemic is driving an increased demand for Medicaid coverage. In order to adhere to basic adequacy standards, a delicate balance of maintaining the minimum enrollee-to-provider ratio, maximum travel times to the closest provider, and the average number of enrollees in service areas must be consistently met.

Applying Innovative Solutions

One tactic TOG Network Solutions has been able to deploy in recent months to help its clients address the sudden influx in Medicaid recipients has been to leverage the expanded availability of telemedicine providers. Guidelines in certain states allow for certain deficits in the minimum enrollee-to-provider ratio to be remedied by offering telemedicine access to patients.

Consider Us a Resource

Every provider network faces different challenges and TOG Network Solutions tailors innovative cost and time saving solutions to fit individual needs. Consider us a resource if you have questions or want to better understand specific regulatory requirements to strengthen or protect your provider network.