If you’ve just arrived in the U.S., common medical terms might be a bit confusing to you. The entire healthcare system is a bit convoluted to foreigners, especially those who live in countries with public healthcare. Most notably, many users don’t understand what healthcare provider network refers to.
To clear the air, we’ll explain what this phrase refers to and why is not having a provider network so risky.
What is a healthcare provider network?
When getting insurance, medical users actually acquire services from a particular healthcare provider network. These networks consist of numerous individual physicians, hospitals, and clinics, which are obliged to provide support in case of medical emergencies and routine checkups. Medical facilities and medical practitioners that don’t belong to your designated network are considered “out-of-network” providers.
Keep in mind that each healthcare plan is connected to a specific network. That way, when you’re getting insurance, you’re also connected to a set of providers that can assist you. Receiving medical aid from other hospitals and clinics that are out of network will be charged 100%.
Why do we use healthcare provider networks?
There are several good reasons why practitioners and medical facilities are clumped up into networks:
- Grouping hospitals and clinics together into one network makes the whole insurance and medical assistance process easier to streamline
- Having networks is also much easier for insurance businesses as they can ensure the same quality of service for all patients. All network members are submitted through the same credentialing process (learn more about this by checking Andros website), which makes the level of service relatively similar no matter where you go
- When all these entities are clumped together, it’s easier for insurance companies to negotiate pricing. The same max costs are applied to all members, which might also reduce how much patients have to cover
Having networks is great for everyone involved. Besides streamlining the administrative process, insurance companies can provide the same level of care for all patients.
What do networks include?
It’s worth noting that payers won’t accept just about anyone in their networks. They use a set of quality standards and requirements when signing contracts with external entities, which are called network adequacy standards. Unfortunately, this can be a double-edged sword.
Having strict standards might prevent payers from having a big, flexible network. As a result, some of the patients might not receive good enough protection, which can potentially affect coverage guarantee. So, payers need to give new members enough time to adapt to their policies.
Whatever the case, these are crucial elements of a good healthcare provider network:
- Each network needs to have a specific number of specialists to cover the potential needs of all patients
- The network should be able to provide a 24-hour emergency service to all patients
- Lastly, the network needs to encompass emergencies where all patients would simultaneously ask for the same type of assistance (i.e., pandemics)
If a payer can’t fulfill obligations to their patients, their clients can ask for proper compensation.
Different types of health plans
Aside from understanding the network basics, it’s also vital for users to learn more about different health plans. Keep in mind that your coverage will vary based on the plan you have, which can be a difference-maker when you get sick.
For more information on available health plans in the United States, you can visit for additional details https://www.medicareadvantageplans2024.org. Here is a short breakdown of different health plans provided in the United States:
- PPO (Preferred Provider Organization) is a common plan that comes with a list of preferred providers. The insurance companies encourage patients to visit these practitioners. However, it’s worth noting that you can also go with hospitals and clinics that aren’t on the list but, in that case, you won’t be fully covered
- HMO (Health Maintenance Organization) plans are much more restrictive compared to PPOs. In fact, when you go with this option, you’re forced to choose a PCP or primary care physician who will perform all your checkups. As compensation for this lack of flexibility, HMOs come with lower premiums
- POS (Point-of-Service) is a type of plan that allows its members to pay lower fees when using a network provider. But if you wish to see a specialist, you’ll first need a referral from your designated PCP
- EPO (Exclusive Provider Organization) can only cover services within the network. The only exclusion to this rule is emergencies
Issues with out-of-network providers
Ideally, you should always go with providers that are a part of your network. If you receive medical care from professionals who aren’t part of your health plan, you’ll have to pay full price while also having to tackle a few other issues:
- Out-of-network providers can charge you up to 100% of the difference between what your health plan covers and what they charge (also referred to as balance billing). As a result, you can get hit by a massive bill, which otherwise doesn’t happen with your regular medical providers
- Many health plans don’t have the coinsurance that would otherwise cover out-of-network services. In other words, you might get hit by maximum coinsurance when using these providers.
- There are also situations where out-of-network practitioners and hospitals don’t charge the health plan, in which situations you’re supposed to bill them.
The only good thing is that the insurance company is always supposed to cover emergencies, whether you’re receiving healthcare from a network member or an out-of-network provider.
How do you choose a provider network?
There are lots of small things you need to consider when choosing a provider:
- Understand different types of healthcare networks
- Learn more about the hospitals, clinics, and doctors that are a part of the network
- Find where all the members are located and, if you need a specialist, if they’re close to your address
- Check providers’ online reviews and overall feedback
- Consider the travel coverage
Ideally, you should look for networks that can provide specialized care. As most of us have tendencies toward certain health issues, it’s best to find good doctors who can assist you with specific ailments.