In and Out of Network Issues
Since three in four health plans include some provision for choosing in-network or out-of-network medical care, the majority of patients covered by health plans in America need some basic understanding of what their healthcare network is and what happens if they go outside of it. In general, HMOs, PPOs, and other Managed Care plans use a provider network, while basic Indemnity Plans (where the insurance plays a flat 80% of charges, for example) do not.
A network, or a provider network, is a group or listing of healthcare providers (doctors, clinics, hospitals, etc.) that has contracted with your insurance company to provide medical care. Because those providers have agreed to accept discounted reimbursement rates from your health plan, your plan wants you to go to them for your medical care, and may penalize you if you don't.
Fortunately, most provider networks are pretty expansive. With many health plans, you'll find that the list of in-network doctors, for examples, includes nearly everyone in your area who you would ever consider going to. Many times, the contracting is done at the group practice or hospital level, so every physician practicing with that group or (in less cases) that hospital is automatically part of your network.
Some provider networks, however, are stringent and may force you to make a difficult decision: Seek your medical services from providers whom you would typically not go to, or pay potentially significant out-of-pocket costs for going to a non-network provider.
If having to research your health plan's network for preferred providers wasn't enough, there is vagueness around complex cases. What happens when you go to an ER that is a thousand miles away from home where, very likely, you won't find any in-network providers? What happens when you have a major surgery and only four of the six doctors involved are part of your network? Hopefully, a good benefi ts department at your employer has already thought about these possibilities. In all too many unnerving cases, however, the patient ends up with either a surprisingly large bill or months of phone calls to clear everything up.
The bottom line: If you are part of a health plan that uses a provider network, do your homework and know about the network. Next, we'll look at a few strategies for being an astute user of your network.