by Cheryl Nash
An increasing trend in payer products are plans with narrow or limited networks. Touted as a move towards providing better care while reducing cost, these plans can be hard to spot by a practice unfamiliar with the nuances in reading the product names, network types, and abbreviations noted on the patient’s insurance card. Practices need to be aware. Just because you participate with the Carrier does not mean you are in network with the Product.
Most are familiar with the terms PPO and HMO, but there are also EPO (exclusive provider organization), POS (point of service) and HDHP plans. While PPO and POS plans provide coverage for both in and out of network (OON) providers, these networks may consist of a limited physician pool based upon a provider’s preferred status or even the state and county they are located in. Claims processed OON will carry a higher patient responsibility in those cases. For other types of products such as traditional HMO’s and EPO’s, the patient may not have any OON coverage and be left with the entire bill to pay out of pocket (OOP). HDHP stands for high deductible health plan and may be structured as an HMO, EPO, or PPO.
Narrow networks are formed by partnering with providers willing to accept a lower fee schedule in exchange for a broader pool of patients. Parameters can be variable and not necessarily linked to quality of care. Instead cost savings seems to be the driving factor for network inclusion. Other considerations can be hospital affiliation, location, and competition among specialists. Simply requesting to be added as a participating provider in a narrow network plan is likely to be declined.
Many patients who purchase these products are unaware of the consequences of their choice. A lack of basic education regarding coverage, OOP expenses, and requirements for PCP referrals, along with locating a network provider is common. Many patients are surprised when they are told their visit is not covered by their plan and they will either need to seek care elsewhere or be self-pay. Additionally, many practices are caught unawares and placed in the awkward scenario of explaining to an unhappy patient after a receptionist indicates they are in network and it turns out they are not! While it is ultimately the patient’s responsibility to verify if the physician they are seeking care from is in their network, if a practice unknowingly leads them to believe they are participating when that is not the case it can cause unnecessary ill will. Not ideal in the age of online reviews.
A great tool to utilize is the payer’s website to see if your physician in included in a network search. For example, UHC has a plethora of these products available and a quick search of their webpage will show a drop-down menu of all the products associated with your practice’s zip code. You can then look up your physician or practitioner to see if they are included in a particular plan’s provider list. It is important to educate your front office and billing teams to learn how to recognize the card differences, notice when a new card comes across their desk, and alert the appropriate individual if there is any uncertainty regarding network status. Just a few minutes of research can prevent some very costly mistakes!
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