A provider network is a group of health care providers — primary care providers, specialists, allied health professionals, hospitals and other related services contracted with a health plan to provide adequate care to its enrollees at negotiated rates. Network adequacy requires that comprehensive health care services are provided in sufficient quantity and quality to serve the population of insured individuals. However, it is important to recognize that provider networks are a critical way health plans manage both the quality of the providers their patients are seeing as well as costs. It is essential to maintain a balance between access to varying types of providers, while still allowing health plans to design lower cost products to best meet the needs of patients.
Plans are required to post information about which providers are in-network and which providers are accepting new patients. But this information is sometimes difficult to access and may be out of date.
Full and current information regarding in-network capacity is critical. Significant challenges have occurred when providers and specialists listed as in-network are no longer seeing new patients, or when available in-network specialists are at significant distance from insured patients, requiring long travel times that limit access.
Other challenges may occur within a hospital or healthcare system when not all specialists are contracted with the same insurer as part of a provider network, even within the same institution. Patients enter a hospital, choosing it as “in-network” only to discover after discharge they have an unmanageable and unpredictable bill, because one of their specialists was not in network.