Most of us have all been in the same situation before-seeking out a healthcare provider that may be the most convenient by proximity or specialty-only to discover they are "out-of-network" and the insurance company won't foot the bill.
It's an easy frustration to have and may be confusing. Sometimes you can see a provider that is in-network only to discover a few months later they are out-of-network, and you never changed insurance plans.
Before you yell into the phone, get mad at your doctor or the facility staff you think is to blame, keep in mind all of the moving parts that go into determining if your doctor is covered by your insurance plan.
In-Network vs. Out-Of-Network: What's The Difference?
The difference between a healthcare provider being considered "in-network" vs. "out-of-network" with an insurance plan boils down to if they are "enrolled" with an insurance plan.
This will have a drastic effect on how much your out-of-pocket expense will be.
You still have the option to see a healthcare provider which is out-of-network, yet depending on your insurance plan, the co-pay can be significantly higher. If you are experiencing a medical emergency or cannot wait for a doctor's office to open, all types of insurance plans help pay the costs of medically necessary emergency room visits and urgent care services.
Types of Health Insurance Plans:
When it's not an emergency, the type of insurance plan you have is a significant factor in how much your wallet will be hurting. Here is a breakdown of common types of health insurance plans and how they differ in costs when a patient goes to an in-network healthcare provider vs. an out-of-network healthcare provider:
Preferred Provider Organization (PPO): A PPO is a health plan that contracts with hospitals and healthcare providers to create a network of options. A patient will pay less out of pocket when they use providers that belong to the plan's network.
Exclusive Provider Organization (EPO): A managed care plan where healthcare services are covered only if a patient sees physicians, specialists, or goes to a hospital that is in the plan's network. There are exceptions in the event of a medical emergency.
Health Maintenance Organization (HMO): A type of health insurance plan that usually limits healthcare coverage to doctors who work for or contract with the HMO. Similar to an EPO, an HMO usually will not cover out-of-network care except in the event of a medical emergency. Additionally, an HMO may require the patient to live or work in its service area. HMOs often provide integrated care to fully or partially blend behavioral health services with general or specialty medical services with a focus on prevention.
Point of Service (POS): A type of insurance plan where a patient pays less when they use doctors, hospitals, and other healthcare providers that belong to the plan's network. A Point of Service plan requires a patient to get a referral from their primary care physician in order to see a specialist, no matter if they were previously established as a patient under a different health plan. This is also the case for some HMO insurance plans.
No matter which one of the above insurance plan types you have, your healthcare provider must complete medical credentialing and payer enrollment.
While they are separate processes, they are also closely connected:
Payer Enrollment and Medical Credentialing:
Before a hospital, medical facility, or healthcare provider can become enrolled in an insurance plan, they must complete credentialing.
Medical credentialing helps to ensure a healthcare provider is qualified to do the job and provide the level of patient care that they signed up to do. Credentialing is a long, slow process that can take anywhere from a few weeks up to several months and involves the collection of a provider's licenses, education history, medical malpractice history, and a variety of other documents to validate their ability to practice medicine.
Collecting and verifying the authenticity of these documents provides healthcare organizations with the ability to attest to the quality of care offered to their patients-as well as the ability to complete payer enrollment.
Payer enrollment is the process healthcare facilities and providers must undertake to receive reimbursement from insurance plans, thus determining if they are "in-network" or "out-of-network" when it comes to how much a patient will pay out of pocket.
The application forms to enroll with an insurance plan can range between 25 pages and 54 pages in length. The time it takes to manually complete the payer enrollment process could be up to 90 days-not including the time spend on credentialing.
In an ideal world, payer enrollment should be automated and completed within the same software platform that a facility uses to complete medical credentialing due to the requirement of all the verified documentation discussed above.
Intiva Health, based in Austin, Texas, describes their company mission as "improving the health of healthcare." One way that they do that is with their credentialing and compliance platform known as Ready DocTM, which also offers payer enrollment within the same dashboard where medical credentialing is completed. Their software enables facilities to complete medical credentialing and payer enrollment faster, which in turn benefits their patients with more insurance plan options.
While payer enrollment and the accepted insurance plans are ultimately up to the individual medical facility and provider, that decision directly impacts the happiness of the patient.
The Bottom Line:
No matter which insurance plan you have, if it is private, through your employer, or government funded, the impact on your wallet still boils down to if your healthcare provider is enrolled with your plan.
Healthcare facilities, administrators, and sometimes individual providers owe it to their patients to accept as many insurance plans as possible to provide coverage for a greater portion of the population.
Research shows that patients are more than willing to travel a greater distance to see a healthcare provider that is enrolled with their insurance plan. While patients must be mindful of how complex the payer enrollment and medical credentialing process is, providers and facilities must take into account how to best serve their patients and take advantage of digital solutions to expedite the administrative processes.