A primary feature of this new blog and web site can be found on the home page and in the top menu: the Network Contract Watch.
Why does this matter?
The vast majority of health coverage plans in the United States — but not all! — make use of a provider network. Provider networks are created by negotiation of contracts between payors (the carriers) and providers (health care professionals). While the ins and outs of provider network contracts are extremely complicated and involve legal professionals, this is essentially what they do:
- The providers agree to discount their rates for patients who use that payor.
- In return, the payor agrees to “drive” its members toward these payors, so that they can make up the discounted rates with higher volume.
- Payors often do this by severely limiting members’ coverage for care that’s received outside the network, up to and including not covering it at all.
There are a number of reasons that provider networks exist, and a full explanation of that would take an entire post of its own. The important part for consumers to understand is that their out-of-pocket costs are always going to be lower for care received from providers in the network, with the difference easily running into hundreds or thousands of dollars.
Thus, network contract negotiations between payors and providers directly impact consumers’ out-of-pocket expenses. That’s you — and your money!
Provider network contracts run for an established period of time. At the end of the contract, the provider and the payor must re-negotiate the terms of the contract. This allows both parties to keep prices and practices up to date.
The catch is that provider network contract expiration dates don’t necessarily coincide with benefit enrollment periods. In fact, given the vast majority of enrollment periods used throughout the industry — including the ACA open enrollment each fall — it’s safe to say that most provider network contract dates will actually not match most enrollment periods.
Or, in other words: the definition of in-network provider can vary throughout the plan year. It doesn’t only change at open enrollment. The provider who was in-network last week could become an out-of-network provider this week. That’s why it’s important to check that your provider is still in the network every time you receive care.
It’s also why it’s important to be aware of major changes in your carrier’s provider network. That’s where the Network Contract Watch comes in.
Why are you doing this? What are you trying to accomplish?
I’m in a position where I often receive notifications when provider network contract negotiations turn difficult or get too close to their expiration dates without a renewal. It’s also a topic that I look for on news feeds.
In the past, when I was a broker account manager, I often only got them for Georgia and I would usually reach out to affected clients so that they knew what was going on. Rumors tend to fly when negotiations get tense, so I wanted to proactively provide reliable information.
Now that I’m in a more national position, I have begun watching contract negotiations not just in Georgia, but everywhere else as well. I had kept hoping to find a site or a service that tracked all of them, but I couldn’t. Since network providers are a pretty important topic, I couldn’t let that slide. That was the genesis of the Network Contract Watch. It’s the most frequent type of update you’ll find here on this site.
My intent for the Network Contract Watch is to create a resource for those who are trying to keep track of major changes in provider networks. I decided fairly early on that, since I’m doing this part-time and manually, I would limit the scope to commercial (group) health coverage, and to large and/or locally significant providers. Generally, this will mean hospital- or university-based systems, but I’m open to including other types of providers if they’re locally significant.
Keep in mind: I’m doing this part-time and on my own.
As of this writing, I’m building the updates list as I receive new updates. In time, it’s my hope that, via some judicious use of WordPress’ tagging function and a couple of handy plugins, this will effectively become a searchable record of several years’ worth of network contract negotiations. I can even imagine it eventually becoming a database; but unfortunately, my database programming skills are not up to the task. I’m an employee benefits specialist, after all, not a database administrator. 🙂
A little bit of legalese
I should be careful to note that provider network contract negotiations are usually considered proprietary information. While I’m sometimes privy to some of those details, all updates I post here can be publicly sourced on the web (and I credit my sources). Or, in other words, I do not post insider information. Further, if a carrier or a provider explicitly asks me not to publicize something — or even to take down an update I’ve already published — I will honor those requests.
At this point, it also makes sense to remind readers that this blog and site are for opinion and information only. Items you see here definitely shouldn’t be considered official statements from my employer, any other broker/agent, any carrier, or any health care system that I mention. I always recommend that readers “trust, but verify” before taking any action based on information you see on this site.
If you happen to have comments, questions, or suggestions about the Network Contract Watch, I’m definitely open to talking about it; just drop me a line. Happy contract watching!