In-Network Doesn't Always Mean Covered

Being in-network with an insurance company doesn't mean you're in-network with every plan they offer.

This is something I wish more practice owners and patients understood.

Insurance companies often offer multiple networks under the same payer. Some are broad networks, while others are limited or restricted, including certain HMO, employer-specific, and narrow-network plans.

And here's where it gets complicated: Not every network is available for providers to join, and insurers don't always make it easy to identify which plans fall under which networks.

You can be fully credentialed and contracted with an insurance company and still be considered out-of-network for a patient who carries that company's insurance.

This can create confusion for patients who understandably assume that if you accept their insurance company, you accept their specific plan.

So, what should practice owners do?

• Understand your contracts. Know which networks you're participating in and recognize that participation may not extend to every product offered by that payer.

• Educate your patients. Explain that accepting their insurance company does not guarantee participation in their specific plan.

• Encourage patients to verify their benefits. Patients should contact their insurance company to confirm that your practice is in-network for their specific plan, not simply ask whether you accept their insurance company. Provide them with the language to use when contacting their insurance payer. Share your NPI with them. This can be included in your intake paperwork as a general document.

• Verify when possible. Your practice should also verify eligibility, benefits, and network participation when that information is available. Remember that verification is not a guarantee of payment.

The bottom line: A patient's insurance card might say Anthem, Aetna, Cigna, or UnitedHealthcare, but that alone doesn't tell you whether your practice participates in their particular network.

The more clearly we communicate this distinction, the better we can help patients understand their coverage and reduce unexpected billing issues.