October 09, 2018
Humana Fined $700,000 for Inadequate Anesthesiologist Network
On October 8, the Texas Department of Insurance (TDI) announced that it fined Humana
, Texas’ fourth largest health insurance writer and ninth largest HMO, $700,000 for failing to maintain an adequate number of physician anesthesiologists in Bexar, Harris, and Travis counties. The Texas Society of Anesthesiologist (TSA) was instrumental in bringing Humana’s inadequate networks in multiple counties to the attention of TDI. Sherif Zaafran, M.D., FASA, Noah Bunker, M.D., FASA, and TSA advocacy staff met with TDI Commissioner Kent Sullivan and his staff to report directly about anesthesiologist group contracts being terminated mid-contract and related concerns for patients assumingly receiving care without their knowledge from out-of-network physician anesthesiologists at in-network facilities.
Texas network adequacy laws require Humana to contract with enough providers to meet its obligation to provide health care services. Beginning in January 2018, Humana had a sufficient number facility-based anesthesia providers but by June contract terminations resulted in an unacceptable decrease in contracted facility-based anesthesiology groups with no in-network facility-based anesthesiologists in dozens of facilities. Humana failed to disclose the decrease prominently or in a timely manner. Humana’s actions resulted in patients receiving care at in-network facilities from out-of-network physician anesthesiologists – some of these Humana enrollees received balance bills. Humana will hold patients harmless and their financial responsibility will not exceed in-network cost sharing requirements.
ASA is working closely with states and physician organizations to ensure appropriate network adequacy laws are in place. ASA further advocates that in instances where a provider or service is out-of-network, a balanced mechanism must be in place to determine fair payment.
Read the Consent order for PPO and group plans
and Consent order for HMO plans