Selecting an In-Network or Out-of-Network Provider...what does it mean? What's the difference?
When a physician or mental health provider is a contracted provider in a particular health insurance plan, that’s considered being "in-network."
Providers are considered "out-of-network", if they have not signed a contract with an insurance company to be in the insurance plan's "panel". However, they may still be covered on a PPO or insurance-choice plan.
There are different insurance plans. HMOs or other limiting plans require their members to seek services solely from their "provider panels" (i.e., "being in-network or a preferred provider panel". The term "preferred provider panels" are the insurance industry's marketing name for their in-network plans. They prefer their members select the providers in their in-network panel plans as the providers contract to accept lower rates. It does not mean the providers are more qualified providers. Provider panels may limit the choice of the insured to obtain some needed care or care by a provider with higher skills, expertise, or experience, even though some highly skilled providers may be in the plans. It's important to look at the credentials of any provider, whether in or out of network.
Out-of-network PPO plans usually allow greater choice for the insured. These plans will enable the individual or family to seek the care they prefer, not be forced to select from a limited list of professions.
In-network means a provider has signed a contract with an insurance company, which includes fixed fees the insurance company allows the provider to receive, an insurance company’s ability to access that provider’s client records, and results in the provider’s clients being insured members of that insurance carrier. It gives the insurance carrier control of the members and providers. In order to receive reimbursement, and coverage for members, in-network providers must provide any records the insurance company wants, whether or not the client wants those entire details released. In-network may result in lowered costs to members due to insurance plans contracts with providers.
If you have an EAP (Employee Assistance Program), it is similar to an out-of-network provider. Insurance companies are not involved until you reach the EAP's allowed session limits. Sometimes, diagnoses are not required and limited documentation is needed (which usually involves DOS-date of service the session was provided and TOS-type of service (such as diagnostic session which is the first-initial session and if session was an individual, marital, or family session). EAPs do not usually require copies of case notes, such as insurance companies may require, but check with the policies if you have an EAP.
Out-of-network providers choose not to be in an insurance carrier’s network. This may provide greater control for people to choose care based upon credentials, skills, and expertise of the provider. It also affords greater confidentiality to the client, as out-of-network providers have ability (because they do not have a legally binding contract with the insurance carrier) to provide only basic information documentation such as diagnosis, type of service, date of service, provider's credentials, brief overviews, in OTRs-"Out-patient treatment reports"). Costs for services may, or may not, be higher, depending upon the specifics of the plans, which are usually PPOs and allow members to choose either in-network or out-of-network, based upon needs of the member. Since an out-of-network provider is not contractually obligated to the insurance company, the client may have greater control over any reports released to the insurance company. This may provide greater confidentiality to clients by using out-of-network providers.
Some providers want to be on insurance panels but do not yet have or need the specific credentials or practice hours to meet state licensing board requirements required by a particular insurance panel. They may currently be out-of-network due to a lack of credentials, hours, or minimum education requirements still to be completed. Once those are obtained, the provider may join specific "provider panels" (to become part of that insurance carrier's in-network providers) and obtain potential referrals from a particular insurance carrier.
Providers may contract with specific insurance companies while not registering for, or being accepted on, other panels of other insurance companies.
Some in-network providers enjoy being in panels, know the "rules" of that particular panel's filing and reporting requirements, or are in group practices where all the insurance claim filing is done by an in-house billing department or out-sourced to a third-party billing department.
Some providers rely upon in-network panels for client referrals, while out-of-network professionals obtain referrals independently of insurance companies, usually through "word-of-mouth" referrals, marketing, credentials or expertise.
Some providers who work with group practices may be in-network if that is a requirement of that group practice or if an insurance company is associated with that group practice.
Obtaining a health insurance plan with out-of-network coverage helps insured members avoid surprise medical bills. This coverage is valuable for those who want to maximize their healthcare options or have specialized medical needs. Some employers offer these types of plans to attract prospective applicants as part of their employee benefits packages.
Some reasons an increasing number of professionals leave or decide not to join insurance panels:
Due to frequent turnover among insurance employees, insurance companies may have employees with limited training who provide incorrect information to their members. This inaccuracy discourages members from seeking oftentimes needed care. Example: A member asks a case manager if "marital therapy" is covered and is told it isn't. But if the member knew to ask for the CPT code 90847, they would find the service they needed was covered. If the member had asked for the code or had asked if family therapy was covered, the case manager would have likely said yes. Members are not usually versed in CPT codes but tend to ask by type of service they are seeking instead. Providers may tell clients to "always file your insurance claims, no matter what your insurance carrier tells you is covered or isn't." Members are often surprised when they receive coverage even if told by insurance companies that they wouldn't. However, the opposite is frequently true. Members are told they are covered, only to later be informed authorized sessions or assumed coverage is denied. It's a common complaint among both members seeking care and providers providing care. There are now groups and attorneys who assist the insured whose claims are denied.
Professionals may be required to join a "group" practice or hire outside billing groups to file insurance claims to receive payment from an insurance carrier.
Insurance panels contract for low rates, which often does not translate into lowered member rates or wages to cover provider's operational expenses which would afford livable salaries for the professional and their needed billing staff. In order to offset costs, they must increase number of clients seen dramatically.
Professionals experience a loss of actual time spent in client care and counseling if having to also deal with insurance companies. Loss of available client care time increases due to the time required to address insurance claims, billing staff costs to file claims, cost of claim submissions, and the time needed to obtain authorization (required by insurance companies to both providers and members).
Professionals want to focus on client care, not "jumping through hoops" many insurance carriers require. Actor, Bryan Cranston, sums up their thinking, "I learned long ago to focus on things you can control and don't even pay attention to things you don't." Out-of-network providers prefer focus on service to clients, not insurance mandates.
Some out-of-network providers believe the "more eyes and hands involved in reporting or billing exposes the confidentiality of a client to a greater extent".
Providers are frustrated at the hoops they must jump through to obtain needed care, or once preapproval is obtained, then an insurance company declines previously authorized care, often making client care out-of-reach for the client.
Insurance companies may deny payment for services a provider has already provided to the insured and this action by the insurance company is adversarial to providers.
Some insurance companies penalize providers (& insured) by covering at a lower rate, hoping to encourage or pressure clients to use insurance company-approved provider lists. In-network p roviders must release any insurance-requested information on a client to any insurance company to which they are a provider (in-network), even if the client wants to keep that information private. Out-of-Network providers do not.
Payments for services, by some insurance companies, are often delayed, even more than the 30-day required payment time period, due to requests by the insurance companies for more documentation from the providers. This delays payment processing and increased staff time and cost for in-network providers.
Every person is different, and there are a wide variety of insurance plans with various requirements and coverage. Some people have choices financially on what type of insurance they can afford, while others don't. Some employers offer only one or a limited number of insurance plans for their employees. Elderly people may be on fixed incomes or Medicare, or those on Medicaid, may be limited in their choice of providers or insurance plans.
But whatever your options are, choose your plan or provider wisely, as much as in your control. That choice can make all the difference.
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