What is a provider network?

provider-network

You likely have a health insurance plan. It might be an individual plan that covers your family. It might be a group health plan that only covers you.

It might be a self-funded group health plan that covers you and your spouse. Every plan is different and the benefits and ways they work vary from plan to plan. But they all have one thing in common: networks.

What is a network? It’s the group of doctors, hospitals, and other health care providers that insurance companies contract with to provide you with health services at discounted rates. You will generally pay less for services received from providers in your network. Networks can vary among plan types, with individual health plans having different networks than group health plans. If you’re a WPS Health Insurance customer, there’s an easy way to find out which doctors are in your network: use our Find a Doctor tool.

So, a network is basically a list of doctors your health plan allows you to visit. Simple, right?

Hang on a second. While it’s relatively easy to define a network, it gets complicated when we consider how health plans actually use their networks. There are different rules for different types of health plans. 

A health maintenance organization (HMO) plan may have a so-called “narrow” network that includes certain health care providers. HMO customers are required to have a primary care practitioner (PCP) and to receive all of their care from a provider who is either employed by or under contract to the HMO. If you receive care from a provider outside the network, the HMO will not pay for that care unless you received prior authorization from the HMO, or your condition was judged an emergency.

A point-of-service (POS) plan takes the HMO to the next level. It allows you to see any providers you wish, with or without a referral. Like other plans, POS plans use networks of contracted health care providers. POS plan customers are encouraged to choose a PCP who becomes their “point of service” for referrals to other health care providers, either in or out of the network. People with a POS plan pay lower out-of-pocket costs and receive richer benefits when they receive care from providers within the network.

A preferred provider organization (PPO) plan offers the highest level of choices when it comes to picking your health care providers. These plans offer a network of preferred, meaning in-network, providers. But unlike HMOs, PPOs allow members to see out-of-network providers. You’ll receive “richer” benefits (the plan will pay more of your costs) when you visit health care providers within the network. PPOs differ from HMO and POS plans in that you do not need to choose a PCP to manage your care. Nor do you need a referral to see a specialist.

What’s the lesson here? No matter which plan type you choose, you can save money when you visit a health care provider in your health plan’s network. Sometimes, it’s nice to have the option to see specialists or other providers outside of the network, but whether that’s something you want or need depends on your unique health and financial situation. Only you can decide which type of health plan is right for you.

If you have questions about your network or what may or may not be covered, ask your health plan’s customer service team. WPS customers have the phone number right on their plan ID cards! It’s easy to get the answers you need to make sure you’re making the most of your provider network.

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