When Providers or Hospitals Leave the BCBSOK Network: Facts You Need to Know
Rising health care costs are a reality for us all. We work to balance what we pay providers and hospitals with what costs are passed on to employers and members. Ultimately, our goal is to provide you with high-quality, cost-effective health care benefits.
What is a network?
A provider network is a set of doctors, hospitals and other health care providers like nurse practitioners, therapists and clinicians that have contracted with Blue Cross and Blue Shield of Oklahoma (BCBSOK) to provide care to you, our members. These providers are called "network providers" or "in-network providers." A provider that isn't contracted with the plan is called an "out-of-network provider." In-network providers generally agree to provide services to our members at a discount.
Why we Contract with Providers and Hospitals
- As the health care industry evolves, and as a non-investor-owned organization, we're accountable to our members for the decisions we make on their behalf. We have a responsibility to make every effort we can to keep health insurance affordable and accessible for all Oklahomans. To do that, we evaluate doctors, health care professionals and facilities and enter into agreements with them that benefit and protect our members. These approved providers become our networks. As part of that responsibility, we continually evaluate our provider networks and actively seek relationships that foster partnership between our organization and providers.
BCBSOK is working to find a balance between quality health care and affordability. One of our statewide initiatives is to standardize costs for non-emergency, outpatient diagnostic services—such as lab tests or imaging services (X-rays or MRIs) --among hospitals and non-hospital-based lab and imaging providers. Hospital MRI rates may be more expensive than those of a freestanding imaging center.
Standardizing reimbursement rates brings hospitals closer to doctors and other providers who render the same services, resulting in fewer out-of-pocket expenses for our member and employers.
- Our role is to advocate for our groups and all our members so that financial and health outcomes are optimized. This means sometimes, due to quality of care, unreasonable financial demands, credentialing and other similar reasons, we make hard decisions to let providers or hospitals go out-of-network. Rest assured that these decisions are not made lightly. We consider the impact these decisions will have on our members, groups and local communities. Changes in reimbursements to hospitals and providers can affect what you pay in premiums and out-of-pocket costs, we try our very best to keep costs reasonable for our members, hospitals and providers. Our goal is to ensure that the outcomes are in our member's best interest.
- We understand that when a provider or hospital in your community no longer participates in our networks, it can affect you. If you have a PPO plan, you have the option to find a new in-network provider or choose to continue seeing your current provider and pay more out of pocket. If you have an HMO, you will need to choose a new, in-network primary care physician. HMO members have out-of-network benefits for emergency care only.
- With more than 800,000 members, we have one of the largest private health care networks in the state. With coverage in all markets across the state, giving you the broadest access to care. Our expansive networks allow members and employers access to affordable health care. Most providers also see our large member base as valuable.
- More and more often, providers and hospitals are making contract negotiations public, by doing things such as sending letters to members and employers and contacting the media. We consider the details of our contract negotiations to be confidential. We try to directly notify physicians, employers, members and other constituents about potential out-of-network issues.
- Contract negotiations with providers and hospitals are a normal course of business. During negotiations, we typically meet face-to-face, have phone calls, email and stay in regular contact. The whole process can take months and involves a lot of people. The vast majority of provider and hospital negotiations end in successful agreements.
- Contract negotiations aren't always about money. In some cases, providers and hospitals want revisions to their contracts other than reimbursement rates. For example, a provider or hospital may ask for a language change to allow a longer time to submit health care claims for their services. We would then have to build in a process to allow for varying timely filing limits on claims, creating more costs in the health care system. Keeping our contracts consistent across all providers helps manage the costs to our members.
- We know the relationship with your provider is important to your health and well-being. We do everything we can to help make sure you can have a great, long-term relationship with your provider.
Ramsey, Lydia. "The Cost of an MRI Can Vary by Thousands of Dollars Depending on Where You Go." Business Insider. Business Insider, 28 Mar. 2017. Web. 28 June 2017.