doctor looking short network

Are Narrow Networks Driving You and Your Staff Crazy?

We hear this comment often from medical practice executives… My practice has participated with ABC insurance plan for years, and our original participation agreement states that we can (or will) be added to other new ABC insurance plans in the future.  Then, why is it that we often receive an Explanation of Benefits (EOB) from ABC insurance plan stating the patient is out of network?  To quote Sheldon Cooper from ‘The Big Bang Theory’… Bazinga!  You have just fallen victim to learning your medical practice is not in this particular network of ABC insurance plan.  The reality is that the patient’s health plan is part of a ‘narrow network’, and your practice was not selected to be a participating provider.


A ‘narrow network’ is defined as a health plan that limits physicians and hospitals available to provide care to the insurance plan’s beneficiaries.  ‘Narrow networks’ aren’t new.  For those seasoned medical practice executives who were involved in medical practice management during the 1990’s, you may remember a variation of this model, called ‘staff model HMO’s.  These ‘narrow networks’ started reappearing shortly after the inception of the Affordable Care Act (ACA), with the emergence of ‘Exchange Health Plans’.  Many insurance plans are attempting to keep their costs down by limiting certain physicians and hospitals from their networks.  In some cases, the insurance plan’s decision may have been based on those ‘loyal’ physicians who provide most of their in-patient care at a participating hospital that is in the insurance plan’s network, and in other cases the selection may have been made based on factors such as ‘quality’ or low-cost care. 

Many employers are choosing ‘narrow networks’ to help reduce their overhead costs for employee health benefits.  Regardless of the reason why a physician or group is able to participate in ‘narrow networks’, the de-selection is causing problems for the medical practice, as well as for the patient.  This may be particularly true for those hospital-based physician groups, such as emergency medicine, pathology, and radiology.  While the hospital and the emergency physician were participating providers, perhaps the radiologist or pathologist were not, and the patient receives an out-of-network bill.


Some insurance plans are even limiting their physician enrollment to a certain number of physicians in a specific primary care or specialty.  If this happens, keep trying to reapply… while you may have previously been denied, it doesn’t mean you will always be denied. 

One article that we recently read stated the medical practice should periodically check the health plans on-line directory to determine if the physician is listed; however, we have heard from medical practice executive colleagues who saw their physician listed in the on-line directory and the claim was later denied because the physician was not a participating provider.  The best defense is to ensure your staff is verifying the patient’s insurance benefits prior to providing care; however, this process is not flawless.

For physicians who are a Texas Medical Association (TMA) member, we recommend that you report the ‘narrow network’ problem using the TMA’s Hassle Factor Log; however, you must ensure your staff has exhausted all attempts to appeal the claim prior to reporting the issue. While there is no guarantee that your claim will be paid with the TMA’s involvement, the Hassle Factor Log provides the TMA with valuable information that can be used during legislative sessions to show elected officials the problems that their patients and physician constituents face while trying to provide medical care.  We also recommend that you report problems to your local county medical society.


‘Narrow networks’ are almost certainly here to stay.  We must all work together to better understand the advantages and disadvantages of these networks.  If you have not been politically involved in the past, it is time to get involved; join the Texas Medical Group Management Association (MGMA) and your local MGMA Chapters, such as the San Antonio MGMA.

One of our consultants attended a seminar that mentioned ‘narrow networks’ and the problems these networks are causing physicians and patients.  The presenter stated that the medical practices are doing a very good job to report problems on the TMA Hassle Factor Log; however, the Texas Department of Insurance is now asking for consumer (patient) complaints.  The seminar presenter stated TMA members can obtain the form letter on the TMA website.

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