Overwhelming Choices in an Open Network
In the 80s I got to learn about healthcare networks because I had to change my doctor. My parents both worked at Lockheed Martin, and they had a new insurance program with a set network of physicians. Unfortunately, my pediatrician didn’t accept the new ID card with the smiley-faced sunshine logo for its network.
I got to learn early on about managed care, HMOs of the 80s, and the referral process. I even got to visit our local Harris Methodist Hospital way over in downtown Fort Worth. I remember (or maybe I have some revisionist history in my memories) the conversations about staying in-network and having to drive a city away because we needed to go where the insurance company told us.
Now, 30 years later, most of us have been on a pendulum that has swung from a small HMO network of providers to PPO networks with almost all providers in the market in-network. As the pendulum swings back, in the last eight years the market has started to migrate to narrower PPOs or EPOs and even some narrow-network HMOs.
But, at the same time that narrow-network plans are becoming more popular, so are “open network” plans. And, open networks, in theory, are awesome. Go wherever, don’t worry about the network restrictions — just go get the best care.
That is actually harder than it sounds.
There is a choice overload for some, and for those that don’t have overwhelming experience with all the extra options of providers, there is a re-education with their trusted doctors that still has to occur because the insurance or plan isn’t what a doctor’s office is used to seeing. The change or emergence of open networks isn’t just new to employees and plan members, it is new to many of the doctors’ offices and their scheduling or insurance billing staff.
Here are some tips to help you navigate this new experience:
- Call the Member Services number on your ID Card, introduce yourself as a new(ish) plan member. Make sure to tell them about any upcoming appointments you have, and ask them to reach out to the doctor’s office with you to make sure you won’t have any issues.
- Most of these plans have an Advocate or Care Navigator. These are typically navigators with clinical backgrounds like Nurses or Medical Assistants who can help guide you to the right providers based on what you need. They also can research doctors using data points that consider quality scores as well as past member experiences. (What do you mean by data points and quality scores?) The Advocates or Care Navigators are way better resources than faulty or purchased internet ratings or asking friends on Facebook, and you should lean on them.
- Ask if your plan has a flyer or education piece for the doctor’s office. Again, most of the good innovative plans that are unlocking your potential as a plan member to visits the best in class providers without network restrictions understand there is a learning curve with the medical community. They have crafted easy to understand communication materials, and most of them ease the learning curve by paying for your appointment that same day or even in advance so that your chosen doctor’s office gets rewarded for seeing you. It is a different experience when your doctor’s office doesn’t have to chase down insurance billing and wait to get paid 60 to 90 days after a visit.
- If you get a bill you didn’t expect, don’t wait. Call, email, or text (yes, text) your insurance company or Care Advocate team a copy of that bill. One of the perks of having an open network plan is paying less for healthcare as a member. Removing the PPO or HMO should remove a middle-man in the exchange of money for healthcare services. And if you don’t loop your insurance or insurance administrator back into any questions of a surprise bill or balance bill, the goals of the plan aren’t rewarded. You aren’t supposed to be penalized for your employer having an innovative plan, so don’t accept unexpected costs. Unlike a traditional plan, these options have safeguards for you. Use them
About the author: An avid learner and resourceful leader with a passion for problem-solving, Bret is a calming force in the chaos and fast-paced evolution of health insurance, employee benefits, and the growing burden of regulatory compliance. He helps people develop the confidence to see beyond the problem at hand and start to re-imagine their goals. Whether he’s helping a client or a colleague, Bret believes a successful interaction is one that allows us all to dream a little bigger when we’re done.
About Generous Benefits: Generous Benefits (www.generousbenefits.com) focuses on solutions that improve the community you serve.