Networks, participating providers, contracted rates

Network status

Network status, par providers, contracted providers, contracted providers… And it comes down to what you pay and how much you.

My insurance with my old employer was with a third party administrator self-insured group called First Choice. First Choice was the network. We had three levels of benefits.

Tier one was services in the hospital itself. I would pay 10% and the hospital would cover 90% of the coinsurance of the services. My deductible was $300 and my out of pocket max was $2800.

Tier two was services in the UW medical system, it was larger, but it was contracted with First Choice also. My benefits at this level still had the same out of pocket and deductible, but I had to cover 20% of the charges and the insurance picked up 80% of the charges.

Tier three was going to a facility or doctor that was contracted with First Choice the network, but not part of my hospital or the UW system. For these services I would pay 40% of the cost, the insurance picked up 60%, plus I had a higher deductible and higher out of pocket for using these services also.

If a facility or provider didn’t contract with First Choice, which is a pretty large network, I had zero insurance coverage and the entire bill was all out of my pocket.

And the contracted service may be related to a specific plan for the insurance carrier.

Coordinated care, for my old employer we would take Coordinated care that was Medicaid, but not the exchange product – Ambetter.

Regence Med Advantage HMO we would be at the 20% co insurance, but Regence Med Advantage PPO meant the patient had 50% coinsurance and a higher deductible.

UHC (United Healthcare) had one group called NPN. We could take NPN patients, but they had to be referred by their doctor and the NPN group. The group was a delegated or capitated group. Easy way to think of this is the clinics were responsible for the medical and have incentive to keep you in their network of clinics to optimize the money side of care.

All this comes down to whether the provider or facility is contracted or not and at what level. That determines the network status of the services you will receive.

What is contracted or participating? Thought we were talking about networks.

Today I was verifying a colonoscopy with Coordinated Care, below is a link to the preauth tool. Do I recommend Coordinated care - no. They just have public access to the preauth tool.

https://www.coordinatedcarehealth.com/providers/preauth-check/medicaid-pre-auth.html

Click no for everything on the little bullets – no inpatient, no dental, etc. Just click no for everything. When you do, a box will open at the bottom and it will say “Enter CPT Code”. Enter 45378. This is a colonoscopy. The menu drops down and has an M beside the code and the words “Authorization is required for non-participating providers only.” If a doctor is not contracted (not participating) with the insurance company, that doctor will require authorization to perform the colonoscopy or it won’t get paid.

Enter 92928 and you will get a Y, all providers need to get authorization for this CPT.

Type in 59510 and you will get a green N. You don’t need to get an authorization to have your baby.

Every insurance and every group inside that insurance has a different set of what they cover and don’t cover. Don’t use this tool for a blue cross product and think it will be the same. And the CPT code even on this website can change from one month to the next as to what needs auth and what doesn’t.

Let’s talk a minute about contracted rates.

Medicare has made it mandatory that all providers to provide access to the charge master, or list of costs for services. And this will confuse the heck out of people.

If a service is listed for $10,000 – that is the self-pay rate. If your insurance is contracted, they negotiate a rate with the provider. For example, First Choice network for that same service would have a contracted set rate of $7000. Blue Cross would have a contracted rate for that service of $6500. Medicare would have a rate of $5500 and Medicaid, for this same service, might only pay $4000.

There is also something called ‘balance bill’. Some providers will send you the bill for your portion that the insurance doesn’t pay, plus the difference between the self-pay rate and what the insurance pays.

If you don’t have insurance, or you have a medi share, you may be able to get a self-pay prompt pay discount of some type. We offered 30% if you paid in 30 days of the bill being sent to you. A $10,000 dollar surgery would cost you $7,000 out of pocket if you paid in 30 days. Hmmmm. The same as the highest contracted rate….

Contracts change every year like underwear. If you are young and have one provider or don’t care who you see, it will be easy to just go with whatever is has the cheapest services close to your house.

When you start getting older or need a specialist, the network status of all your providers and the hospitals where they provide the services from will play an important part in how you choose from the insurance options you have.

If your living in multiple locations, like Arizona in the winter and Washington State in the summer, you need to make sure your insurance actually can go from state to state and allow services everywhere you go.

You need to check the status of how all your providers will be contracted, every year, to get the best insurance coverage for your needs.

One last thing. If you ask for an estimate, they will include the contracted benefit level for that and the self-pay cost if you provide your insurance information when you make the request.

What next – Emergency room and network status.  Because it is a little different.