Are Narrowing Insurance Plan Networks a Thorn in Your Side?

New NCQA Health Plan Accreditation Standards May Help

August 20, 2015 02:45 pm News Staff

The AAFP -- and the family physicians it represents -- are all too familiar with the concept of "narrow networks," a belt-tightening practice undertaken by health insurance companies to reduce their physician networks.

[Family sitting in medical office waiting room]

In 2014, hundreds of AAFP members from across the country alerted the Academy to a trend that family physicians argued interrupted the continuity of patient care and, at times, left physicians wondering if they were in -- or out of -- an insurer's network.

In response, Academy toughened its tone on the issue, and in January, AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., told CMS that the Academy had grave concerns about the practice.

"We recognize that insurers have a responsibility to align networks of physicians and hospitals to maintain affordable premiums while ensuring quality and efficiency," said Blackwelder in a letter to the agency. "However, we feel that disruptions to the patient-primary care physician relationship are contrary to both of these goals."

With that background in mind, it's easy to see the good news in a recent press release( from the National Committee for Quality Assurance (NCQA) that announced the release of its 2016 health plan accreditation standards to emphasize patient access to care and the timeliness of such care.

Story Highlights
  • The National Committee for Quality Assurance recently reported that it has beefed up its 2016 accreditation standards for health insurance plans to better ensure patient access.
  • The 2016 standards include a network management section designed to more closely scrutinize a plan's provider network and give special attention to high volume and high impact specialties such as primary care.
  • Since 2014, the AAFP has been pushing back on the narrowing of insurance networks because the practice has been shown to disrupt relationships between family physicians and their patients.

For instance, the 2016 standards include a network management section designed to more closely scrutinize a plan's network and give special attention to high volume and high impact specialties such as primary care.

In addition, the updated standards require health plans to assess the accuracy of their provider directories to include whether or not such directories provide information about active physician contracts and whether physicians listed in the directory are accepting new patients.

According to the NCQA press release, "Inaccuracies in online or print directories -- a long-standing challenge -- can interrupt or delay care."

The enhanced 2016 standards also seek to ensure that patients receive the right care at the right time. The NCQA instituted new utilization management standards that, for instance, require health plans to notify patients of their appeal rights, and also require plans to make timely decisions about coverage of care and provide patients with accurate reasons when claims are denied.

Patricia Barrett, the NCQA's vice president for product development, said in the press release, "Patients are at the center of everything NCQA does, and the 2016 health plan standards highlight patients as our priority. We want patients to be confident that their NCQA-accredited plan will keep them at the center of every coverage decision they make."

The NCQA lays claim to two decades of health plan accreditation( history and recognizes hundreds of plans that cover more than 136 million Americans.

Notably, HHS selected NCQA as an accrediting entity for health plans participating in the health insurance exchange marketplace associated with the Patient Protection and Affordable Care Act.

NCQA awards health plans five levels of accreditation: excellent, commendable, accredited, provisional and interim; those plans that do not meet NCQA requirements are denied accreditation. The accreditation status of NCQA participating plans is available via the NCQA Health Plan Report Card.(

Related AAFP News Coverage
Letter to CMS
Guard Against Narrow Networks in Medicare Advantage Plans, Says AAFP


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Narrowing Networks Member Reporting Form