What can you do?

The prevalence of doctors, providers and even larger healthcare groups leaving Health Maintenance Organization (HMO) and health plan networks appears to be on the rise.  While we can appreciate or even sympathize with a doctor’s need to make a change, patients are ultimately burdened with having to pick up the pieces to ensure they have continuity of care, especially if they’re in the middle of being treated for a condition.

Providers leave a health plan network for any number of reasons:

• Retirement
• A change in the group’s practice
• Changing professions
• Administrative stress that comes with participating in a health plan network
• Compensation

A provider’s network contract typically gets renewed periodically. One of the most significant reasons doctors will leave networks (or at least threaten to leave) is being unable to negotiate or come to terms on the financial reimbursement of services.  The cost of doing business goes up for every business at one point or another, so who could blame a doctor for wanting to get paid more.  While money is important, sometimes the administrative duties to participate in a network can be too burdensome to manage.

The Financial Impact is Real

If you continue to seek treatment from a doctor who no longer participates in your plan’s provider network, the likelihood is high you’ll end up paying the full charge billed to you, not the lower health plan rate.  If your plan does cover out-of-network expenses, the service will be applied to your out-of-network deductible. While you would get credit applied to the deductible, you probably will need to pay the full charge billed until your deductible is met.  According to Kaiser Family Foundation research, the average In-network deductible for an employer plan is $2,000 for single coverage and $4,000 for family coverage. Out-of-Network deductibles are usually double that of In-Network deductibles.

When a doctor is not participating in a health plan’s network, they are free to charge their normal private rate / street-price.  A $75 In-Network office visit rate would become a $150 or higher rate that you would be responsible for paying now that the doctor is out-of-network.    

When a medical claim is applied to the Out-of-Network deductible, the health plan will still apply only what they think is a reasonable charge for the office visit, and potentially not the full billed charge if higher than their rate. You would only receive deductible credit for what the health plan set as the reasonable rate. 

Higher Reimbursement Rates Could Mean Higher Insurance Premiums

One strategy health care provider’s use to put pressure on employers is to send letters to their patients stating that they plan to leave the health plan’s network because the health plan will not pay for higher rates of reimbursement.  This may come across as a one-sided viewpoint.  Negotiations between health plans and providers occur all the time, especially during contract renewal periods. Such tactics seem to be a way for employees to put pressure on their employers who in turn contact their health plan.

Geographically, one large provider group leaving a network could mean a significant disruption in network coverage.  Health plans want to avoid such gaps in network membership as it doesn’t bode well for their renewal prospects.  Employers will most certainly hear noise from employees who consider traveling a longer distance to find affordable health care. 

If a health plan capitulates to paying higher rates, it could set off a series of unintended financial consequences:    

• First, other health care providers may get wind of such negotiations and will expect higher rates of reimbursement.

• Second, higher reimbursement rates could have an impact on the annual premiums come renewal time. While a health plan could try to absorb the higher reimbursement rates overall, eventually it will catch up and bleed into the costs they pass on to employers. Employers don’t like higher premiums as that means their costs go up. The downstream impact will be to pass on the premium increases to employees through employee payroll contributions. Employers could also compensate for higher premiums by changing the plan design like raising deductible levels or reducing the coinsurance rates from say 90% to 80% for In-Network services which still passes on more of the cost to employees.

Individuals who get their health insurance through Marketplace plans (ACA plans) have no real leverage to influence premiums. The only option is to consider changing plans during the next annual open enrollment period to a health plan where your provider of choice is considered In-Network. This change may end up with the person paying higher premiums. In the end, patients end up being the beneficiaries of healthcare inflation which is a real and immediate burden.

What are your options if your doctor is leaving the health plan network?

Typically, the health plan will mail a letter to all impacted members within 90 days of the doctor leaving the network. This assumes the doctor informed the health plan of their departure. You may also receive a letter from the doctor informing you about the change in health plan network status. Most negotiations end in an agreement avoiding departure from the health plan network, or there’s an extension to the contract to continue negotiations in good faith, thereby postponing any impact on patients. Nevertheless, patients are left in limbo wondering what will happen.

In anticipation, you can look for another In-Network provider. This can be a cumbersome, time-consuming process, you’ll need to search the health plan system for a list of In-Network providers and then contact each one to see if they are accepting new members. New patient appointments may take longer than expected so it’s ideal to jump on this as soon as possible.

You may incur a cost to have your medical records transferred to your new provider. These costs are not covered by your health plan.

What if you are currently receiving treatment and prefer to remain with the same provider, or perhaps you live in an area with limited options for a particular specialty? Changing “provider teams” mid-stream can be stressful, and cause delays or even changes in your course of treatment. Often, a provider who leaves a health plan may be part of a larger group of physicians and health care professionals who are leaving the same health plan network. This can impact a wide range of services and treatment you are receiving beyond the office visits to one specialist. You may also need lab work, medical injections, radiology, physical therapy, mental health and other services that have been delivered by those providers within the same group that is leaving the network.

Continuity of Care Option

Your health plan may offer a special process called Continuity of Care, whereby the health plan will make an exception to continue covering all of your treatment by the providers who are leaving the network while you make time to find another In-Network provider. The approval may cover claims for an additional 90 days as In-Network claims.

While on the surface this sounds great, and your out-of-pocket costs may be lowered for the interim period which is a plus, check with your doctor to see if they will continue to treat you and accept the negotiated rate; the provider may expect you to pay full charge regardless.

You always have the choice to continue with the provider on an out-of-network basis assuming they are not retiring. Nevertheless, financial costs weigh heavily on our decisions. Today, medical debt ranks as the top reason for bankruptcies even for people with health insurance.

If your provider leaves the health plan network, there really doesn’t seem to be too many options available other than finding a new provider if you want to avoid higher costs. You can find a new doctor who is In-Network, you can try to change your plan where your doctor does participate, or request a continuity of care option which is not a long-term solution.

Edited by Sebastian Pokluda

---

• Strategies