Locating an in-network healthcare provider in America is challenging, and it sometimes feels like a losing battle. You go to a doctor you think is in-network, only to find out when you get a bill that they aren’t. You are trying to get an appointment, but every doctor you try that is in-network has a six-month waiting list. Why is this happening?
Complexity of Insurance Plans: Insurance plans often have complex and frequently changing networks of providers. Understanding which providers are in-network can be challenging for patients, especially when insurers update their provider lists or change their network status. The complexity and lack of transparency in these networks make it difficult for patients to know who is in-network without calling each provider.
Limited Provider Availability: In some regions, especially rural or underserved urban areas, a limited number of healthcare providers may be in-network for certain insurance plans.
Provider Referral Networks and Market Competition: Healthcare providers often form referral networks based on professional relationships, shared patients, or institutional affiliations. These networks can influence where and how patients are referred for further care, potentially bypassing in-network options for out-of-network alternatives. Additionally, market competition between healthcare providers and insurance companies may limit the willingness of providers to join specific networks or for insurers to include certain providers, further restricting in-network options for patients.
Starting off with bad data is the biggest issue. Significant gaps exist in the electronic health information and provider network status. These gaps can lead to challenges in maintaining up-to-date, accurate information about provider network status accessible to patients. Moreover, the fragmented nature of healthcare information systems can hinder efficient communication and referral processes between in-network providers.
In future articles, we will go over what to do if you have been to a doctor that you were told was in-network, only to find out later that they are not. Surprise Billing is something the government has been trying to tackle, and for certain populations, you can no longer do this bait and switch where an individual is not aware that they will get billed for a service.