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Struggle Over HIX Provider Networks Will Get Rough

Christopher Cheney, for HealthLeaders Media, February 12, 2014

Insurers say they have to design their provider networks for the new public exchanges with cost control in mind. Critics say excluded hospitals in rural and economically disadvantaged areas of the country are at risk of financial ruin. CMS will try to have the final say this year.

Battle lines are being drawn over the crafting of commercial insurance networks for the new public health insurance exchange marketplace.

Under the banner of "high-value provider network," insurers say they have to carefully design their network of providers to contain the costs associated with serving the new exchange market. With many people getting healthcare for the first time through the public exchanges, payers are bracing for a population of patients with chronic diseases and other costly medical needs.

Creating provider networks that follow accessibility regulations while selectively choosing participating providers is key to making healthcare policies affordable, John Montgomery, MD, Humana's vice president and medical officer for Florida commercial markets, told me last week. "We really had to balance access and service area size with affordability," he said.

On Tuesday, America's Health Insurance Plans released an email highlighting praise for "high-value provider networks," with sources ranging from Health and Human Services Secretary Kathleen Sebelius to academics to analysts to news reports.

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