Network Adequacy for an insurance carrier means that the insurance carrier must provide enough providers in various professions to be able to provide the best care for their members. The care must be able to be provided in a timely manner. Carriers have control over the number of providers that they deem to be ‘adequate’ and many carriers are moving to specialized networks called narrow networks or accountable care networks where the number of providers is limited even more.
WA State Network Adequacy laws
Network access—General standards.
(1) An issuer must maintain each provider network for each health plan in a manner that is sufficient in numbers and types of providers and facilities to assure that, to the extent feasible based on the number and type of providers and facilities in the service area, all health plan services provided to enrollees will be accessible in a timely manner appropriate for the enrollee’s condition. An issuer must demonstrate that for each health plan’s defined service area, a comprehensive range of primary, specialty, institutional, and ancillary services are readily available without unreasonable delay to all enrollees and that emergency services are accessible twenty-four hours per day, seven days per week without unreasonable delay.
Many people in various insurance plans are finding it more difficult to find massage therapists in the various insurance networks. This is due to many massage therapists opting out of networks mainly because of the issue of low pay, the challenges of billing and getting paid. Health insurance carriers in WA usually pay significantly less than what a massage therapist charges their cash clients. Provider lists are also not updated to match the actual number of providers.
If you are not easily able to find a massage therapist close to home or work, please report it to the Office of the Insurance Commissioner.
From the National Association of Insurance Commissioners: “Health insurance carriers generally have the ability to define and adjust the number, the qualifications and the quality of providers in their networks. They also may limit the number of providers in their networks as a means of conserving costs or coordinating care. In so doing, carriers may narrow their provider networks to an extent that enrollees in insurance plans may have relatively or extremely limited options when choosing providers. ” https://content.naic.org/cipr_topics/topic_network_adequacy.htm
What this means for massage therapists
Many insurance networks for massage therapists have been closed since the early years of being able to be a provider. Some open occasionally in specific areas as needed. If you are trying to get credentialed with a carrier, fill out an application even though the list is closed (if possible).
Many massage therapist providers are leaving the insurance networks finding it difficult to make a living on their allowable fees, extra paperwork, demands and dwindling massage therapy benefits as well as prior authorizations that limit care.
In the early days, a massage therapist could also work to show that the network was inadequate in their area by going through the list of providers and calling each one to see if they are taking new clients. Massage therapists who are not taking new clients and are still on the provider network must tell the network that they are not taking new clients to keep the list of available providers up to date. Massage therapists who leave the network must also alert the insurance company that they are leaving. The provider lists are often not up to date so if you could show that their network was inadequate, you could possibly get a spot in the network. I am not sure if that still works as I have not heard of anyone doing that lately.
As network adequacy becomes an issue, you may be able to use this as leverage for negotiating your contract with the insurance company for higher pay.
For more information on how to bill insurance see my book: Massage Insurance Billing Manual on my other site www.massagepracticebuilder.com