When Things Fall Apart: A Roadmap for State Regulators Managing Fallout from Provider-Payer Contract Disputes

By Sabrina Corlette, Emily Curran, and Rachel Schwab

High-profile disputes between insurance companies and providers appear to be on the rise. These disputes, which can end in a provider system leaving a health plan’s network, come with high stakes for consumers, particularly as hospital systems have become more consolidated. Plan enrollees can face disruptions to their continuity of care, reduced access to services, and unexpected expenses for out-of-network care.

In a new report published with the support of the Robert Wood Johnson Foundation, experts at CHIR assess the authority and tools that state insurance regulators have to protect consumers when a provider leaves their health plan network, as well as the procedures used by insurance companies to mitigate the risks of a provider transition. Notably:

  • Consumer protections vary, depending on where they live. We find that some state laws to protect consumers in the wake of a provider termination are stronger than others. Furthermore, while some state insurance departments are proactive in working to ensure a smooth transition for plan enrollees, others are not, and engage only after receiving consumer complaints.
  • Some insurers are better actors than others. Insurers in our study all had policies and procedures to manage the transition to new care providers for plan enrollees. However, state insurance regulators reported that some insurers are better at executing these strategies than others. Ensuring that plan marketing materials and provider directories are accurate and not misleading poses a particular challenge.
  • Several regulatory best practices can prevent misinformed purchasing decisions and smoother care transitions. Regulators and insurance company executives helped identify several optimal policies and practices for states and insurers to implement to better manage a provider termination.

The report provides a roadmap for states and insurers seeking to ensure that consumers make informed purchasing decisions, have access to an adequate provider network, and maintain continuity of care. You can read the full report here.

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