Networks participation is extraordinarily plastic. Providers can leave networks at will, and entry can be anywhere from signing a new contract to being invited in to being wined, dined and sixty-nined until the provider agrees to participate.
In the past year for Mayhew Insurance, providers have left our primary commercial (non-Exchange) network for the following reasons:
- Kicked a provider out after a federal indictment for prescription drug fraud (rare)
- Decided to move to Florida, South Carolina or Arizona to work on the golf game (common)
- Died (uncommon)
- Retired (common)
- Declined to renew as there were not enough Mayhew Commercial members in the region but stayed on as a Mayhew Medicare provider (uncommon)
- Withdrew as Mayhew Insurance signed three more docs within 2 miles of provider’s office location (uncommon)
- Got bought out by an integrated provider-payer organization that does not take Mayhew Commercial (common)
- Meth lab or gas leak explosion two suites over made the facility unusable (happened more than once)
- Removed from the network due to licenses expiring in Mayhew area of service (common)
- Removed from the network due to multiple malpractice claims (uncommon)
- Removed from the network as we no longer selling insurance in those counties (uncommon)
- Why the hell not (common)
- We have not paid a claim to this doc in over three years — why continue the relationship?
- Mayhew Insurance won’t increase reimbursement rates by 50% and Major Competitor Company will pay 30% better than Mayhew.
When evaluating a network, it is quite possible for a doc to be in network today and out of network next week. Sometimes those are mutual decisions, sometimes they are insurance company decisions, some times they are regulatory decisions but most of the network churn in an established network is from provider decisions.