Provider network management refers to processes for credentialing and including/ excluding providers from networks, the establishment of fees for in-network providers, and setting usual, customary and reasonable (UCR) fees for out-of-network providers.
These organizations reported using standard credentialing checks to decide which providers to include in their networks. Some leaders mentioned excluding certain subspecialties (for example, specialty providers of ABA for autism), and reported doing ongoing evaluations of network providers. One industry leader noted that a problem for all organizations is a shortage of psychiatrists in many geographic regions (especially in rural and frontier areas), and that they work hard to credential and include as many psychiatrists as apply. Another noted that exclusion of individual providers was done only on the basis of “egregious” quality issues. All have reviewed their provider network management practices in response to the IFR, and a number of issues have emerged.
Some organizations report having special requirements for masters-level therapists to have post-degree supervised clinical experience (2 or 3 years), because many masters programs do not offer this training and state licensing requirements vary widely for masters-level clinicians. There is no parallel with general medical network providers and they do not require this for psychiatrists or PhD-level psychologists, whose licensing does require supervised clinical experience.
Some organizations discussed challenges related to setting and/or negotiating in-network provider fees using similar approaches to medical plans. For example, some medical plans may use Medicare fee standards (some multiple of Medicare fees), but not all do. Providers sometimes have expectations that their fees should be increased to be equivalent to medical providers, or should be automatically adjusted along with those of medical providers. The industry perspective is that these providers fail to recognize, in the words of one respondent, that “the markets are different.”
According to the industry representatives, establishing UCR fees for out-of-network providers is another challenging issue. Medical plans rely on data obtained from companies that collect and analyze large numbers of claims from multiple payers, but information on psychotherapy is not available from these companies. One organization uses their own in-network data to establish UCR fees; another mentioned less systematic collection of information about UCR fees in local markets.
In response to the IFR, one organization has dropped their provider network inclusion requirement of supervised experience for some clinical subspecialties, while two others have not (on the basis that the requirement is defensible).