Monday, November 14, 2016

Brief Blog: Nails in the Coffin; Anthem Widens its Exclusive Narrow Networks

For the last four years, Dark Report, via Dark Daily blog articles, has discussed the effects on the lab industry caused by narrowing networks and more adverse out-of-network penalties. A few examples are:

  1. 8/2012: Aetna sued by California clinical groups over adverse OON policies; here.
  2. 6/2013: Doctors now excluded by narrow networks, clinicals already there; here.
  3. 10/2014: Narrow networks mean shrinking opportunities for labs; here.
  4. 10/2015: Payers hit labs with recoupments and penalties; here.
  5. 12/2015: Labs, Pathologists, Insurers at odds over balance billing; here.
On November 11, 2016, Los Angeles Times runs a story on how Anthem abruptly switched 500,000 members from PPOs (which by definition have benefits, but different, for preferred and other providers) to EPOs (exclusive provider networks) with NO out of network benefits.  The article, by Melody Peterson, is here.  A California watchdog group brings the issue before a state superior court judge in November.  

The case hinges on the timing and the fact pattern; while one group asked for a restraining order, "Anthem said it had explained the change to consumers in renewal letters" and that "state officials had approved the change to EPOs."   

For an NEJM article, November 2016, on going to an in-network E.R. but getting out of network doctors, see here.  For follow-up in NYT, here.  NYT writes, "Once patients get to the emergency room, they have little choice over who treats them. “To put it in very, very blunt terms: This is the health equivalent of a carjacking,” said Zack Cooper, an assistant professor of health policy and economics at Yale University, and a co-author of the [NEJM] paper."