What you need to know about medical provider networks

What is a network of medical providers?

A network is a group of medical providers, such as doctors, hospitals, laboratories, therapists, etc., who contract with a health plan to provide services to its members at negotiated rates. Provider networks allow health plans to control costs and protect consumers from overcharging or other billing issues.

Which networks should include

Health plan networks must follow state law (leg.wa.gov). This means that they must:

  • Include some types of providers, such as women’s health practitioners, tribal and rural health care services and centers, primary care physicians, and mental health care providers.
  • Have enough numbers of each type of supplier to meet the anticipated needs of consumers.
  • Provide 24 hour emergency care.

If you are having difficulty receiving services from your health insurance plan, file a complaint with our office. We can follow up with the company to make sure you can access the care you paid for.

REMARK: We do not have the power to order health plans to include a specific physician or medical facility.

Risks associated with the use of an off-grid supplier

If you see a health care provider who is not part of your Medicare network (a group of doctors, hospitals, and other health care providers), you could pay a lot more . Here are a few things to consider:

  • An off-grid health care provider may charge you 100% of the difference between what they charge and what the Medicare plan pays. This is called “balance billing”. This can leave you with an unexpected and large bill. Network providers cannot do this.
  • Some health insurance plans do not apply the coinsurance you pay for off-grid services at the cost limit. You may have to pay unlimited coinsurance amounts for off-grid services.
  • Some health plans do not cover off-grid services at all.
  • If you have an emergency, your health plan should cover costs at the network level until you are medically stable – even if you have to go to an off-grid hospital.
  • Off-grid healthcare providers don’t have to bill the healthcare plan, so you may need to.

What to do before choosing a health plan

Before signing up for a health plan, confirm with your health plan and health care providers that they are part of your plan network. Networks change, so you should also periodically confirm your provider’s network status, even after signing up for the plan.

Individual health plans sold through the Washington Health Benefit Exchange (wahealthplanfinder.org) may offer different provider networks than those you buy directly from an insurance company.

Questions you should ask

Your health plan:

  • Does the health plan use provider networks?
  • Does it cover services if you see an off-grid provider?
  • Is there a separate deductible or higher coinsurance for off-grid services?
  • Is there a limit on the coinsurance you pay for off-grid services?

Your medical provider:

  • How do you recover your deductible, your co-payment and your coinsurance with me?
  • How do you charge for the services?
  • Are the laboratories networked?

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