Do Your Employees Know Where Their Network Is?
Your employees probably know that to get the most benefit from their Preferred Provider Organization (PPO) health plan they should use service providers that are within their PPO plan networks. What many employees with PPO coverage probably do not know is just how easy it is to unintentionally use out-of-network physician services.
One common way for an employee to unintentionally go out-of-network is for them to visit an in-network hospital where they end up being treated by an out-of-network physician. Your employee is probably unaware that in-network hospitals could have physicians – such as radiologists, pathologists, anesthesiologists or even assistant surgeons – who are not in the network with the hospital. Often the patient does not have much say in selecting these providers. It may depend on who is on duty or the attending physician’s preferences. The unfortunate result is that the employee gets a large and unexpected balance due bill that isn’t reimbursed by the plan.
Actually, this problem has been around as long as 1979, when negotiating Preferred Provider Networks was first allowed in California. Providers who choose not to contract with networks can continue to set their own billing rates. While the Affordable Care Act (ACA) imposes annual limits on how much individuals pay out-of-pocket in addition to the benefits paid by their insurance, the ACA out-of-pocket limits do not apply to out-of-network charges in excess of the in-network allowed amount. It is important to educate plan participants to keep this situation from happening in the first place.
Explaining how your employees can avoid accidentally going out-of-network is a great way to help them become better health care consumers and potentially save themselves a significant amount of money. Help them understand the resources your health plan has to identify the providers within their negotiated network – online or through the plan’s member services center. Communicate with them about each plan’s policies for out-of-network providers at an in-network hospital, and let them know how to communicate with their physicians in advance that they want their services performed by providers in their network.
The next time one of your employees is using their health care coverage, they might think twice and realize that your education efforts helped them avoid some unwelcome medical bills.