Problems with Health Provider Networks?

The White House is addressing two of the weaknesses in the Affordable Care Act: inaccurate provider directories and the out of pocket costs of consumers. (cf. New York Times 05/09/15). These two issues are the most common consumer complaints. In this blog I will address inaccurate provider directories.

To help my clients, I research carrier websites to ensure that their doctors are in the network of the insurance company of their choice. However, when they visit their doctor some of them find that their doctors left the network and are faced with higher out of pocket costs. The White House is working to alleviate this problem by requiring insurance companies to update the provider networks once a month. If a company fails to do so they will face financial penalties. While this will help, this will not eliminate the problem.

The impetus is to hold the insurance companies accountable. The reason this will not eliminate the problem is that it fails to address the doctors’ and facility’s responsibility. Doctor’s and facilities may leave a network when their contract is up. If you are in the middle of a cancer treatment and your oncologist decides to leave your insurance company’s network, you are forced to find another oncologist. What we need is a federal mandate for doctors and facilities to “grandfather” a patient. This would mean the patient continues treatment and the doctor/facility accepts the contract payment until treatment is completed. This, unfortunately, does not help those who do not have a serious condition. Your doctor may be in the network this month and decide to leave the next.

There is no easy solution to this problem. The White House action is a good first step. To protect yourself as much as possible work with a health insurance agent to research your providers before choosing an insurance company. Then ask your provider if he intends to stay within the network. And when you are planning major work, ask the question again.

Maria Barron, Health Benefits Consultant

Design by Likoma with WOO on WP