Some insurers' narrow networks include a mismatch among providers where in-network doctors don't have privileges at any of the in-network hospitals.
In California, for example, pediatricians often send children to urgent care clinics when they need medical attention in the evening or during weekends. But consumers who purchased an Anthem Blue Cross plan through the state's health insurance exchange don't have in-network coverage at one particular clinic, reported the Sacramento Bee.
Even though pediatrician Nelson Branco, M.D., is an in-network doctor in the plan, if he refers his patients to the clinic, they will have to pay out-of-network fees. That often leads to parents taking their children to the more expensive emergency room.
"It's really a mess," Branco told the Bee. "The after-hours clinic has kept thousands of patients out of the ER and saved thousands of untold ER dollars. Now, to limit access to the after-hours clinic is really just shooting ourselves in the foot."
Doctors aren't the only providers complaining about the mismatches--hospitals also want a solution to narrow network problems caused by health plans failing to sort through the physician admitting relationships, the article noted.
But insurers say the mismatches should be rare because they designed the networks "to include physicians with admitting privileges to hospitals in the network," said Lindy Wagner of Blue Shield of California. She added that Blue Shield is working to educate doctors about their participation in plan networks while also adding doctors to its networks.
Such discrepancies may lead to tougher restrictions for insurer networks. The Centers for Medicare & Medicaid Services already proposed a policy requiring payers to expand their networks to include essential community providers or risk being kicked out of the marketplaces, FierceHealthPayer previously reported.
To learn more:
- read the Sacramento Bee article