As narrow provider networks become more widespread, healthcare payers and regulators are focusing on the ground rules for out-of-network care payments. Chiropractic and telemedicine practitioners may benefit.
Key questions about narrow networks are becoming clearer.
With exclusionary underwriting such as pre-existing condition culling outlawed under the Patient Protection and Affordable Care Act, provider network design has emerged as a key tool for payers to control the quality and cost of healthcare services.
The first stage in the evolution of these so-called narrow networks focused on the adequacy of provider networks, with regulators setting service accessibility standards for patients such as travel distance limits.
As state and federal officials finalize provider-network adequacy standards, billing for out-of-network healthcare services appears destined to dominate the next evolutionary stage of narrow networks.
Robin Gelburd, president of New York-based FAIR Health, says establishment of ground rules for out-of-network care should be a top transparency goal in the healthcare industry.
"Out-of-network care is squarely in the spotlight now, but there are two major prongs to that discussion—elective out-of-network care and 'the surprise bill.' In elective out-of-network care, there often is a unique issue or a pre-existing relationship with a physician who is no longer in the payer's network. When there is a lack of transparency in these elective out-of-network cases, there are unexpectedly high out-of-pocket costs for patients. If there is going to be cost-sharing for this care, it's better for patients to know that before they get a service," Gelburd told me recently.
"With the surprise bill, a patient thinks that a service is covered at the in-network rate, but the bill includes an unexpected out-of-network fee. This is the exacerbation of the times."
FAIR Health is a not-for-profit corporation founded in 2009 to gather and leverage payer claims information. The organization has taken a leading role in healthcare transparency efforts, including provision of data used to set pricing benchmarks for New York's recently adopted healthcare transparency law.
Gelburd says the Empire State's healthcare transparency law, which includes consumer protections for patients who seek out-of-network services, reflects a growing regulatory trend.
Christopher Cheney is the senior clinical care editor at HealthLeaders.