Navigating Narrow or Focused Provider Networks (Part 2)

140052962By Elizabeth Kay
Compliance and Retention Analyst
AEIS, a UBA Partner Firm

Health care reform has brought about many changes and growing pains. One of the changes we have seen recently in 2014 is the increased use of focused or ”narrow” provider networks. While these were implemented by the insurance carriers in the individual Marketplace to help control premium costs, we have seen the subscribers of employer sponsored or group plans affected as well, but it’s not in the way you might think.

Just before 2014, we talked with our clients, who are also providers, and informed them about the smaller networks ahead of time. This is so they could check with their carriers to confirm if they were going to be considered participating providers in the smaller networks to help avoid confusion, as many of them were not even aware that carriers had more than one HMO or PPO network that they offered. 

Later in 2014, we started receiving phone calls from some of our other clients and their employees complaining that they were unable to get in to see their doctors. They were being denied access to the same providers that they had been seeing for years, with their same insurance coverage, due to the provider citing that they no longer accepted their insurance carrier. 

Now, according to the insurance carrier, their providers were still contracted in-network providers, so why would they decline to accept their insurance?

Well, it turns out that the provider had seen some patients that had coverage with a carrier with whom they were contracted. However, upon submitting the claims to the carrier, the claims were not paid by the carrier because the insured had been issued coverage through our state Marketplace exchange with access to a narrow network, not the full carrier network.

To make matters more complicated, this particular carrier had used the same prefix and numbering system for the subscriber numbers of enrollees from the individual state Marketplace plans and enrollees in employer sponsored or group plans. 

Therefore, when the provider submitted claims for those enrolled through their employer, those claims were being declined by the carrier, even though they should have been accepted and paid.  But, because the subscriber numbers looked the same as those of individual enrollees, the claims system rejected them as it was coded to process claims based on the subscriber number, and not by another factor such as a group number.

As a result, the provider began denying any patients that had coverage through this carrier because they were not getting paid, and thought that their contract had been suspended or terminated.

After we had gone back and forth between the provider and the carrier, we finally discovered what the problem was, and they fixed the problem.

Once they were able to correct it, those provider’s claims that should be paid because they had coverage through an employer sponsored plan would be covered, as they had access to the full provider network. But providers were not really educated about any of this, so they were still denying patients.

We contacted the providers on behalf of our clients that had reached out to us with this problem and were able to educate them. We asked that they re-submit the claims for our clients. One billing specialist was in some disbelief, but we told her that we had confirmed with the carrier that the claims for our client would be paid, explained why the claims were declined in the first place, and finally convinced her to complete the re-submission process not only for our client, but for others that had been declined as well. We then took an additional step and told them the proper questions to ask their patients about what kind of coverage they have so that they can avoid having claims declined in the future.

So, I suppose the moral of the story is to educate, be informed, and be aware that even if you don’t have a plan with a narrow or skinny provider network, you can still be impacted. But as long as we keep calm, stick together, and have knowledgeable advisors to rely on, then we will be able to overcome these growing pains together.

Bring it on, 2015, we are ready for you!

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