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For example, what if you had to stop at one particular grocery chain and show a membership card to get fresh broccoli? Or what if you could send text messages from your phone freely, but if you needed to send an email, you’d have to get prior authorization from the primary account holder? Or if at the movie theater, you had to shell out $600 to see the latest superhero movie, but if you wanted to watch a “generic” version without the star actors, you would pay just $15.
But you get our point. Health insurance, provider networks, and payments are all complicated and confusing in a way other goods and services aren’t. Whether you’re a consultant, broker, or benefits manager at a self-insured employer, it’s tough to keep up with the constant changes in this industry. And you are the experts—this stuff is your bread and butter. Imagine how tough it would be to keep up on how healthcare works if you were a graphic designer or a warehouse shipping manager instead.
One of the hardest things for employees to understand is “in-network” vs. “out-of-network” claims. It’s not as simple as choosing a hospital system and sticking with it, or choosing a doctor and seeing them in any office or clinical setting. However, advisers and employers who are great at “network steerage” are great at benefits cost containment.
Network steerage is the strategy payers use to ensure their population is visiting in-network doctors and facilities. These networks are carefully negotiated and thoughtfully planned to give patients access to convenient, effective care near them. Large employers or employer groups will sometimes partner with health plans to ensure access to in-network care for their staff.
Network steerage can also help with health outcomes. Healthcare payers (including self-insured employers and carriers) drive patients to facilities that offer better outcomes and better care. These are known as “Centers of Excellence,” and they aim to provide members with access to doctors and facilities known for high quality health services.
For example, let’s say you tear your ACL playing basketball in a rec league. You know you’ll need surgery, and you need to find an orthopedic surgeon who can fit you in soon. First step: you log into your carrier’s website and search for in-network surgeons. You find one nearby that’s labeled “in-network” on the website. You decide to double-check, so you call his or her office, but they tell you that they don’t accept your insurance at the hospital where the surgeon has privileges.
Why not? It’s tough for members to understand these nuances of the healthcare industry. While an orthopedist might be in-network for office visits, their hospital association might be out-of-network, and that’s where you’d be having your surgery.
Next step: check your carrier’s website for in-network hospitals, then choose a surgeon who operates there. Your carrier may have selected these hospitals as part of their network or as Centers of Excellence because the data shows better patient outcomes, a lower re-admittance rate, or lower costs for procedures.
Members who don’t go through this process of double-checking their network might find themselves with higher out of pocket expenses. We calculated the out of network overspending on major orthopedic procedures using the Artemis Platform, and here’s what we found.
For each member who has a major orthopedic procedure out of network, it costs the employer over $1,000 in overspending. This is where employer education can really shine. Self-insured employers, consultants, and brokers should engage in frequent, clear and timely communication with employees to make sure they’re using in-network providers and facilities. It’s good for both parties: employees pay less for great services, and payers do too.