Patient prepares for insurance department hearing

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News,Business,Insurance Industry

CONCORD, N.H. (AP) — A Rochester woman will formally ask the state Insurance Department on Wednesday to include her physician and others affiliated with Frisbie Memorial Hospital in the provider network for those buying individual health plans under the Affordable Care Act.

The department is holding a hearing at the request of Margaret McCarthy, who wants to overturn its approval of Anthem Blue Cross and Blue Shield's new network. The proceeding will resemble a trial, with McCarthy, Anthem and insurance department officials questioning each other and presenting arguments to Insurance Commissioner Roger Sevigny, who will serve as the judge.

Anthem and the department have said the network — which includes 16 hospitals, 78 percent of the state's primary care providers and 87 percent of specialists — meets or exceeds all state adequacy standards, and that the state can't require an insurance company to negotiate with a particular provider, let alone contract with one. But McCarthy's attorney, Jeremy Eggleton, argues that state regulations give the department broad power to either order an insurer to correct a deficiency or fix it itself.

"I think the commissioner could say, 'Based on the evidence, there's no reasonable way you can fill the gap in this network without including Frisbie Hospital,'" he said Tuesday.

Eggleton said his testimony will focus on showing that department didn't get the information necessary to fully evaluate Anthem's proposed network, and if it had, it wouldn't have approved it.

Rules require insurers to submit information about whether consumers are having trouble accessing health care, including data about which providers are accepting new patients and how long patients must wait for appointments, Eggleton said. While Anthem may argue that it couldn't do so before the network had actual policy holders, he argues that it could have drawn upon its past data as the dominant player in New Hampshire's individual insurance market.

Under state standards, a network is adequate if 90 percent of a population has access to a primary care physician within 15 miles. While that is true for the whole state, it is not the case in northern Strafford County, the area served by Frisbie and where residents tend to have lower incomes, Eggleton said.

"This is where the population is that is going to be signing up on the network, they're not in Dover and Durham," he said. "That's where they should've concentrated their providers."

Anthem officials have said that including all hospitals would have driven up premiums because network hospitals agreed to reimbursement rate concessions in exchange for the promise of a certain volume of patients. A company spokesman did not respond to a request for comment Tuesday.

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