Narrow network plans and verifying patient insurance coverage

In my last post I discussed holding the claim for patients with traditional medicare as the primary insurance. I also discussed Medicare Advantage plans. To refresh your memory, Medicare Advantage plans are private commercial plans that “replace” traditional medicare when a patient assigns his or her medicare benefits to that plan. Patients frequently choose to do this for lower premiums, drug benefits (part D is often covered), but tradeoffs are that copays and coinsurances may (or may not) be higher. One big tradeoff is the networks might be narrow.

These are different from supplement plans, which usually “pick up” the 20% that Medicare does not pay, although sometimes there’s a copay or coinsurance. What makes it even more confusing is that some companies sell both types of plans- AARP has a medicare complete (advantage) plan as well as supplements; so does Humana. As long as you are credentialed with Medicare, the supplement will (almost always) pay, even if you are not credentialed with Humana.

Approximately 30% of Medicare eligible patients are enrolled in Medicare advantage plans. This number varies by state and is steadily increasing. They are often narrow network plans, meaning there are only a few doctors in town that patents can see. They come in two flavors: PPO and HMO. PPOs often have out of network benefits, whereas HMO plans do not. Politicians often favor these plans as a way to keep costs down because the plans are paid a fixed amount per patient. Many ophthalmologists are concerned that as the number of enrollees in Medicare Advantage narrow network plans increases they will lose access to patients to bigger groups, but you can often get in network even as a solo doctor if you are aligned with the right hospital system.

My opinion is that these plans game the system by making the network so narrow that it is difficult for patients to get in to see a doctor, or they exclude “expensive” specialists say oncology specialists or rheumatologists who prescribe biological therapeutical drugs. Once the patient gets serious or expensive health problems, they can switch back to traditional Medicare, which has a bigger network but will probably have more out of pocket costs.

This makes the Medicare advantage plan look like they are “keeping patients healthy”. These advantage plans can often require authorizations, which leads to more work for your office, as well as the chance that a code is missed, leading to zero reimbursement to your office.

Often times, their contracted reimbursement rates are a percent of Medicare- if you introduce a middleman they’re gonna take something out. Frequently big groups contract with these plans because they are willing to take lower reimbursement in exchange for high volume. Then they hire someone recently out of training and have them see a ton of patients.

It is absolutely vital that everyone who runs their own solo practice understands what a narrow network plan is and how as well as whether or not they are contracted. When I opened doors, I was contracted with Blue Cross Blue Shield (BCBS) of Arizona- but this did NOT mean I was contracted with certain BCBS plans, such as BCBS Alliance (the exchange plan) or BCBS Medicare Advantage. I was only contracted with their PPO. You need to read your contracts and ask your reps about the different types of BCBS (or other insurance) plans that are offered, and figure out how to contract with them.

What makes it even more confusing is that these plans often have different reimbursement rates. For example, BCBS Alliance has the same contracted rate as the PPO, but the BCBS Medicare advantage plan is a percent of Medicare.

Certain ACOs (Accountable care organizations) or IPAs (Independent Physician Organizations) may allow you to contract with narrow network plans. This is why it often makes sense to get hospital privileges with multiple hospital systems in your town (as long as they aren’t unreasonable about the call you take)- it often helps you credential with plans.

Another example is United Health Care. I am in network for the UHC PPO, but NOT in network for the UHC Medicare Advantage plans such as AARP complete, which is a narrow network Medicare advantage plan (note that this is different from AARP as a supplemental to Medicare, which usually picks up the 20% not covered by Medicare as covered in my last post). I am also NOT in network for the UHC Community plan, which is a Medicaid plan, although the UHC community plan will pay me up to their allowed amount as secondary to medicare. If a patient has the UHC community plan as primary, I get nothing because I am out of network. Again, the UHC PPO has a different reimbursement rate from the Medicaid community plan, which has a different contracted rate from the Medicare Advantage plan.

For Aetna, I am contracted for Aetna PPO, as well as their Medicaid program Mercy Care, but NOT with their Medicare advantage plans, Aetna prime and platinum. I was also out of network for Aetna Leap, their exchange plan (this plan went away). And Aetna has a plan called Aetna Banner which is through the ACO Banner Health network, which I am not part of, so patients with this insurance are out of network for me- even though I am contracted with Aetna PPO.

One example of how a IPA helped me get on a plan was with HealthNet. When I tried to contract with them directly, they told me their panel was full and to take a hike. I got into their network through their affiliation with ASPA (Arizona State Physicians Association). HealthNet also has a Medicare Advantage plan, but they make it especially confusing; I am only in network for HealthNet Medicare Advantage Medicare essentials and Green, but NOT for Ruby and Jade. Got it? Of course, when I first opened I accidentally saw about six patients in Ruby or Jade. I got stiffed on these patients.

Definitely make a table of the plans you are in network for, as well the ones you are out of network for. Make sure this is easily accessible to your front desk. You can (or rather should) put this list up on your internet site, so referring offices can easily access the information. I routinely drop off updated lists with referring offices. If I get in network for a narrow network plan, I make sure to use the online directory to look up primary care doctors in the area, so I can tell them I can take their referrals for that plan.

How do you know the patient has a narrow network plan? If the card says PPO on the front usually that means you’re in network, as long as you’re contracted. If it says HMO it’s obvious that it is narrow network. Anything in between, you can either try to use your practice management system, insurance company website, or even google the plan to try to get help.

We learned the hard way that any Cigna City of Phoenix employee is in a narrow network plan and can only go to see doctors that work for Cigna facilities. (I am also out of network for the Cigna Medicare Advantage HMO). Often times, once you are credentialed, if there is a new plan the insurance company will send you a letter indicating whether or not you are in network (as well as a sample card).

We don’t make the same mistake twice! This is why everyone should do their own billing- when you get a zero EOB from being out of network, you can investigate the insurance card and find out why. No billing company will go out of their way to do this for you. The balance will just get written off, and you won’t learn from the mistake and continue to see more patients in the plan you’re out of network for and continue to get zero EOBs.

As stated in my last post, your practice management system should be able to verify whether a patient is enrolled in traditional medicare or in a replacement plan (scroll down to the bottom of benefits and it will say HMO with name of the plan). One wrinkle I have found as there are a lot of snowbirds in Arizona: often, a Medicare Advantage HMO from another state (say BCBS MN Medicare Advantage HMO, which obviously I am out of network for) will allow you as out of state to bill traditional Medicare, which pays 80%, and BCBS MN will pick up the remaining 20%. So get your front desk to make a phone call (or search google) to find out!

I didn’t know ANY of this when I first opened. I learned on the fly. If only if I had this blog post to read back then. Don’t make the mistake of seeing patients you are out of network for, or ones enrolled in Medicare Advantage HMOs that present traditional Medicare cards to you. Always verify everything.

This sounds confusing at first and some of you will want to join a group so you won’t have to worry about any of this- but the problem with a group is that they won’t train their front desk to do this as well as you can. Read this post, read your contracts, ask your insurance reps, follow up on your zero EOBs and you’ll be in good shape.

3 thoughts on “Narrow network plans and verifying patient insurance coverage

  1. Excellent article. Can you explain in a future post as to the benefits and disadvantages of joining a clinically integrated network (CIN). Here in Ohio, 2 major hospital systems have their own CINs but my billing/credentialing company told me their payments will be even lower than regular payments. The advantage they seem to have is that credentialing will be done for all major plans free and would be able to get in network with all plans, atleast from what I understood. However, the amount they pay should definitely be lower since there is a new ‘middleman’. Thanks and keep writing!! These are very informative.

    • We will soon have a post up about venture capital buying practices and doing the same thing.

      CINs styled as you describe were a big trend in the 90s and went away. You can do your own credentialing and don’t necessarily want to take all plans if rate too low. Worse, being in a CIN may discourage referrals from doctors outside of the CIN.

      In theory ACOs which I participate in are CINs, but as a specialist you can participate in more than one ACO and you still keep your own TIN and control over your practice, at least for now.

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