Recently, a report came out siting California as one of the top four states to host a high percentage of what is know as Narrow Networks. Narrow Networks may have been around for awhile but I am seeing an increasing number of problems with medical claims in these narrow networks since 2014.
First, if a provider doesn’t know that an insurance has narrow networks, they aren’t asking the right questions when contracting and credentialing and may not understand that once their is an executed contract with a well known payer, they may not be part of their narrow networks. Even when calling insurance companies, you have to understand how this works or you won’t ask the right questions and not all payers are forthcoming with this important detail.
Second, most consumers have no idea how their insurance plan works overall, let alone how narrow networks could impact them financially. The assume if I have X insurance and I call my provider and they say, “Yes, we take X insurance”, that means, yes, their provider is part of their network and all they will be responsible to pay is co-pay and any deductible or coinsurance splits and will assume their In-Network benefit structure is at play.
The greatest problem happens when claim is submitted. The provider will provide service in good faith they will be reimbursed by their patient’s insurance plan and either will receive a smaller reimbursement from insurance, with a greater patient responsibility or claim will deny out right as not covered and receive no reimbursement whatsoever from patient’s insurance. This leaves a greater financial out of pocket expense for patients who are unprepared for the medical bills that will arrive in the mail months later.
This is a no-win situation for providers or their patients. Traditionally, we have seen a greater reduction in insurance reimbursement to physicians over the years and they are already running their practice on very small margins. Putting a greater out of pocket expense on their members and not clearly outlining this plainly to patients as they are purchasing these plans puts providers in more and more of a burden, as the cost of collecting from a patient after the service has already been provided. Spending valuable resources to staff knowledgeable front office staff who can vet each patient’s plan out in order to determine if they really ARE in their network can be costly.
MEDELECT, Inc. can take the burden off of both providers and patients through our Benefits Check Services and Contracting and Credentialing Management, please contact us today for a free consultation.
To read more about the recent study visit: http://www.californiahealthline.org/articles/2015/8/26/75-of-california-exchange-plans-have-narrow-networks