PROVIDER PROTECTIONS

Non-Discrimination Against Certain Health Professionals
Health plans cannot discriminate against providers who are located in geographic areas that contain high-risk populations. Nor can they discriminate against providers who treat patients that present a risk of higher-than-average claims or use of health care services (NCGS 58-3-200(e)). This section is intended to ensure that health plans do not intentionally exclude certain providers from their networks because they are more likely to treat high-risk populations.

Gag-Clauses Prohibited
Health plans may not limit a provider’s ability to discuss clinical treatment options with their patient, whether or not these options are covered under the benefit package. Health plans may not limit providers’ professional responsibilities to patients (NCGS 58-3-176(a)). Physicians and other providers have an ethical duty to explain all treatment options to their patients, regardless of whether the health plan will pay for the treatment.

Providers Protected From Retaliation When Filing Appeals on Behalf of Members
Health plans are prohibited from discriminating against providers who appeal a plan’s decision affecting the availability, delivery or quality of health care services. For example, an HMO cannot retaliate against a physician who appeals the HMO’s decision to deny or limit care (NCGS 58-50-62(j)).

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