By NextBestFitStronger network adequacy rules and audited directories
Keep networks but set strict distance and wait standards, with fines for 'ghost' directory listings.
Draft decision:RejectedConfidence: high · not yet reviewed
Unneeded once networks end.
Review ledgerHow this path connects
This path
Stronger network adequacy rules and audited directories
Creates or worsens
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Set national time-and-distance and wait-time standards for networks
- Require monthly directory audits with fines for ghost listings
- Pay out-of-network care at in-network cost sharing when standards are missed
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Narrow networks and out-of-network surprises
Distance and wait standards and fines for inaccurate directories improve access while preserving narrow-network premium savings with little disruption. Network complexity and out-of-network risk remain.
What it creates or worsens
- Requires difficult enforcement
Enforcing network standards is difficult because regulators rely on insurer-reported data.
Who's affected
Who gains
- People with ongoing or specialist care needs
- Narrow networks and out-of-network surprises: Needed specialists and therapists are often out of network.
Who loses
- Health insurers, brokers, and their shareholders
- Narrow networks and out-of-network surprises: Narrow networks let insurers offer lower premiums.
- Hospitals and specialist groups with high private prices
- Narrow networks and out-of-network surprises: Out-of-network providers can bill high charges.
Where it has been tried
- U.S. secret-shopper audits: Audits found many listed providers unavailable.Sources: Polsky et al., NEJM (2015)