Occasionally, medical doctors and/or health facilities and health insurance carriers enter negotiations for better rates. Insurers and doctors can renegotiate their contracts mid-year, which means, depending upon the outcome of this type of negotiation, employers may find themselves in a difficult place with the doctors and hospitals their employees know and trust now considered outside their health coverage plan network.
How does this happen?
When an insurer and a doctor/hospital are unable to reach an agreement on a contract, the contract ends. This means that potentially thousands of employees/members may have to find new doctors, or suddenly pay out-of-network rates.
This can be painful for your employees, especially those in the middle of treatment or dealing with a serious illness. Inevitably, some people would blame the insurer. Others might blame the doctor.
Your employees may also be wondering, why are insurers and doctors allowed to change networks mid-year, and what can you do if it happens to your company’s health benefit plan?
Why would doctors and insurers do this?
Insurers are under significant financial pressure to streamline and reduce costs. One way of accomplishing this is by negotiating — or renegotiating — reimbursement rates with various hospitals in their region.
If a hospital is unwilling to accept an insurer’s new rate, they leave or are dropped from the carrier’s network.
This isn’t an outcome anybody particularly wants. Hospitals don’t want to lose their patients, but they also don’t want lower reimbursement rates. Insurers don’t want to cut a hospital from their network, but they also don’t want to overpay.
The negotiation comes down to which side has more leverage. If the insurer has a large group of members, the hospital might be more willing to accept lower rates, because they need that group of patients. If a hospital has very specialized services that members demand access to, the insurer may be willing to pay higher rates to keep their customers.
What happens if your employees suddenly lose access to their doctor?
If your health insurance network changes mid-year and your employee’s favored healthcare facilities or doctors are no longer included in-network, your employees will have to decide to switch doctors or consider out-of-network care which has its own inherent problems. Here’s a few things to consider on behalf of your employees:
- Getting care out-of-network can be financially risky
- Your employees will lose their health plan discount if they choose to go out-of-network. They will not be protected by their health plan’s discount any longer, so services and treatment may cost more.
- Your employees will lose their health plan discount if they choose to go out-of-network. They will not be protected by their health plan’s discount any longer, so services and treatment may cost more.
- Your employees’ share of costs for treatment will be higher
- When your employees go out-of-network for treatment or services, their share costs will be higher, including deductibles, copays, and/or coinsurance. How much higher will depend on what type of health insurance they have at the time of service.
- When your employees go out-of-network for treatment or services, their share costs will be higher, including deductibles, copays, and/or coinsurance. How much higher will depend on what type of health insurance they have at the time of service.
- Your employees may be balance-billed
- When your employees use an out-of-network provider, not only can that provider charge whatever they want, they can also bill for whatever is left over after the health insurance company pays its part (assuming your insurer pays anything at all towards an out-of-network bill). Called balance billing, this can potentially cost employees thousands of dollars.
- When your employees use an out-of-network provider, not only can that provider charge whatever they want, they can also bill for whatever is left over after the health insurance company pays its part (assuming your insurer pays anything at all towards an out-of-network bill). Called balance billing, this can potentially cost employees thousands of dollars.
- Employees may have problems with the coordination of care
- Moving from network to network, there may be communication challenges and member’s care and coordination of services may be compromised. Ultimately, the onus will be on the employee to make sure that their former in-network doctors’ information is sent to the new in-network doctor.
Consider switching insurance carriers to retain access to doctors and providers your employees know and trust.
PHP knows the importance of employee choice and maintaining relationships with a doctor is crucial to your employee’s health and well-being. We maintain relationships with all large regional hospital systems and associated physician groups – Parkview, Lutheran, and IU Health.
Considering switching to PHP, your employees will get to keep credit for deductibles and out-of-pocket maximum expenses which they have met for this plan year under their prior health plan and retain access to the doctors and providers they know and trust.
If you want to see if a doctor or healthcare facility is part of the PHP network, use our Find A Doctor or Facility tool.
Talk to your broker or a PHP advisor today by calling 260-421-4500 or visit PartnerwithPHP.com.