How do you solve a problem like provider data? Part 3: Insurance Network

Stephanie St. Thomas
July 15, 2020

This is part of a series on provider data. Check out Part 1 and Part 2.

How do you feel about surprises? While most of us like the kind involving gifts and cake, there are others we’d rather avoid.

My health plan website says this doctor takes my insurance. Now that I’m here, the receptionist is telling me the visit won’t be covered.

I received an expensive bill because my health insurance didn’t cover the anesthesiologist during my outpatient surgery.

If you’ve had these kinds of insurance-related surprises, you’re not alone.

One in 10 insured Americans said that within the past two years, they were surprised to find that a doctor, lab, or facility that they thought was in their insurance network actually wasn’t.

Among privately insured patients who received specialty mental health treatment, 44 percent used a mental health provider directory to find care. More than half found inaccuracies in the directory. As a result, they were 40 percent more likely to be treated by an out-of-network mental healthcare provider and four times more likely to receive a surprise, out-of-network bill.

Even the most diligent and careful consumers can be confused by similar-sounding plan names with very different networks. Provider office staff are equally frustrated, since answering a patient’s simple question about coverage can involve searching through many sites. And insurance companies struggle to reconcile constant changes in provider contracts and locations with the public-facing information in their online directories.

Numerous plans, narrower networks

Much of the health insurance network confusion relates to our complicated healthcare system.

The typical health insurance company serves many markets, including Medicare Advantage, Medicaid, commercial health plans (such as employer plans), and health exchanges established by the Affordable Care Act. Medicare Advantage plans and health exchange plans are increasingly likely to be narrow network plans, and some employers are offering these types of plans as well. Narrow network plans are more affordable than other options but feature a more limited choice of doctors and other healthcare providers—or many choices within a certain health system and limited or no coverage with another.

According to the Robert Wood Johnson Foundation, the number of plans on the individual market offering out-of-network benefits fell from 58 percent in 2015 to 29 percent in 2018.  

Given these changes, understanding your health plan network is more important than ever—and also more difficult.

Constant contract negotiations and insurance network changes

To keep healthcare costs competitive, insurance companies frequently renegotiate contracts with providers and change the structures of their health plans. For example, an insurance company may want a doctor to be in-network when she practices at Clinic A, because that whole clinic is part of a specific health plan network. Across town at Clinic B, the same provider may be out-of-network.

The growth of independent medical groups—such as anesthesiology groups—further complicates the situation. For example, the surgeon who conducts your outpatient surgery could be in your network, but the anesthesiologist might not be, resulting in a surprise bill. A recent JAMA study reviewed nearly 350,000 elective surgeries involving patients with employer-provided (commercial) health plans. Although the surgeries had been performed at in-network facilities, by in-network primary surgeons, patients still received out-of-network charges 20 percent of the time.

Embedding network information in a comprehensive provider directory

Insurance companies would like their directories to reflect every provider contracting change in real-time, but it’s a technical and administrative burden to track contract changes across thousands of doctors and multiple networks.

At Ribbon Health, we regularly speak with health insurance companies, healthcare providers, and digital health companies that rely on accurate provider directories to power a variety of use cases. We work with these companies by offering a simple distribution to our accurate, comprehensive data layer – powering unprecedented scale and ease of use.

As a result, insurance companies can offer cleaner, up-to-date directories, provider offices can refer patients with confidence, and digital health companies can help consumers navigate to the right, in-network care for them.

These improvements add up to a simpler, better healthcare experience for all. I invite you to learn more about how Ribbon Health can help you.

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