Health Plans, Networks, and Provider Relationships Work Together for You

By February 18, 2019February 19th, 2019Featured Health Insurance
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Health plans often reference their provider networks, describing providers as either in-network or out-of-network. Provider networks include a range of professionals, from nurse practitioners to physical and occupational therapists, in addition to both primary care physicians (PCPs) and specialists. When a provider is in a plan’s network, it means that the plan and the provider have a contractual relationship. These relationships guarantee certain fees for services and other details of how the provider will interact with a plan and its members.

In-Network and Out-of-Network Providers

In-network providers generally cost you less than out-of-network providers do. Because of their contractual relationship, you will pay lower copays or coinsurance for the services you receive from in-network providers.

Under most circumstances, if you have an HMO plan (which stands for Health Maintenance Organization), you are required to choose a PCP from your plan’s provider network, and you’ll probably need to use in-network providers to ensure that your plan will pay for any covered services you receive. If you have a PPO (Preferred Provider Organization), your plan may pay for covered services from out-of-network providers, as long as you meet certain requirements, and you probably won’t need to choose a PCP. Either way, understanding your plan’s provider network can save you money.

Getting More from Your Network Providers

Some carriers, including Independence Blue Cross health plans, create preferred provider programs for high-quality, efficient providers. Participating providers are chosen for these preferred provider programs because they meet specific criteria and certain quality metrics. Physicians and other providers in these programs come from some of the largest and most respected practices.

If you choose to see one of these preferred providers, you may pay less for your visits, too! Contact your plan to find out how your providers are being measured, and how you can make these preferred provider relationships work for you.

Website last updated: 1/8/2019

Y0041_HM_19_73133

Accepted 2/15/2019

 

Rob Smith

About Rob Smith

Rob has worked in the Medicare and Medicaid health insurance field for over 22 years. He has worked for several regional and a national Blue Cross Blue Shield plans with responsibilities for product development, marketing, compliance, sales operations and sales management. In his current role as Vice President of Product Development, Sales, and Marketing – Medicare at Independence Blue Cross in Philadelphia - Rob has overseen the redevelopment and repositioning of Medicare Advantage with unprecedented growth and retention. With a renewed commitment to innovation and partnership with the Centers for Medicaid & Medicare Services Independence Blue Cross in now it its second year of participating with the value based insurance design (VBID) demonstration.