Centene is facing a lawsuit that its networks are too narrow and that not all of the docs that it says are in network actually accept their Ambetter individual market insurance.
Centene’s Coordinated Care subsidiary faced a fine and regulatory action by Washington State regulators in December. They failed to have an adequate network.
Coordinated Care Corp. has agreed to a consent order detailing steps it must take to fix its provider network deficiencies and other ongoing issues. The company was fined $1.5 million with $1 million suspended, pending no further violations over the next two years…
In particular, Coordinated Care admitted to not having enough anesthesiologists in King, Snohomish, Pierce and Spokane counties. According to the company’s own data, its provider network is also seriously deficient in other categories of providers, including immunology, dermatology, and rheumatology. [my emphasis]
The ROAD specialties are Radiology, ophthalmology, anesthesiology and dermatology. These specialties tend to be high cost and comparatively speaking conducive to good work-life balance for the docs. Centene’s own data shows an issue with two of these specialties. There are two stories that can be told.
The company friendly story is that they are trying to recruit for these specialties and at some point they had an adequate network but someone had the nerve to die or retire on them. Every network manager had that happen to them at least once. They’re trying and if someone really needs a dermatologist, an out of network service will be authorized for in-network cost sharing. That is their story to tell.
The other story is a bit more cynical. We know that Centene’s business strategy in multiple insurer regions is built on cherry picking the healthiest chunk of the population by offering very low cost, narrow network products and spamming the Silver subsidy point. This strategy leads to very large risk adjustment outflows as comparatively few people with high cost or complex medical needs sticks with Centene. They are explicit about this strategy by their pricing, their networks and benefit designs.
The more cynical story is that the lack of ROAD specialists is part and parcel with this story. Dermatology, rheumatology and immunology are specialties that are capable of generating large claims for both the specialist and then follow-up inpatient and pharmaceutical claims. If there are either no one in those specialties or if those specialties can only be accessed after the patient fills in fourteen forms in triplicate in Number 7 pencil, those claims can be averted as the patients who need those types of providers will have decided that the hassle is not worth it. Instead, those patients with their higher than typical risk scores are covered by someone else and Centene pays some risk adjustment money out to partially compensate for the risk transfer.
That is the story that the plaintiffs will try to tell.