Insurance companies seem to love confusing acrynomy. Medical networks are no exception. It does make sense that they seem confusing because if you take a look under the hood of most medical networks you will find that they actually are confusing! In addition to that, much of the information about these networks online is old and outdated. Join us as we attempt to shed some light on the most important aspects of the different medical network types.
HMO Network Explained
HMO stands for Health Maintenance Organization. It is a network of doctors, hospitals and other health care providers who agree to provide care at a reduced rate.
Sometimes HMO’s require patients to choose a primary doctor and run everything through that doctor, including getting preapprovals for some services. However, this is not how most HMO’s work in Georgia currently. Most HMO’s simply require that you go to any in network doctor.
HMOs networks are usually confined to a certain state or area of a state. These networks are targeted to serve a certain are of the population of a state and are usually delineated by county. Even with this smaller network, emergency coverage is still available anywhere in the US.
As a result of these smaller, more targeted networks, HMO’s usually cost less money than PPO and NPOS networks. These savings are passed on to the consumer.
HMO Pros and Cons
- Cheaper Price
- Emergency coverage available anywhere
- Doctor options close to where you live
- Less choice in where to receive care
- Might not have top specialist for certain conditions in network
- No out of network benefits
- No coverage when traveling unless it is an emergency
- Sometimes have to go through a primary care physician for other services
Kaiser’s Integrated Care Model
While Kaiser’s network is classified as an HMO, it is worth noting that it is not really an HMO in the traditional sense. Kaiser employees their own doctors, builds most of their own medical facilities and uses their own healthcare management system across their medical network. This provides an unprecedented level of coordination of care between providers and a level of streamlined and tailed care that you will not find with traditional HMO’s that are just a collection of independent doctors and doctor groups.
Kaiser does not build their own hospitals in Georgia; however, they do integrate their system and model of care into the hospitals they do contract with. Most recently they have signed a 20 year agreement with Emory Hospitals and Emory will be using Kaiser’s integrated care model.
Additionally, because Kaiser doctors are not beholden to an insurance company in a pay for service scheme, they are able to focus more on caring for patients. Kaiser doctors are given bonuses not on volume of patients seen but rather on successful outcomes and patient satisfaction.
This is one of the reasons why Kaiser has been winning awards in Georgia for quality of care for over a decade.
PPO and NPOS Networks Explained
Preferred Provider Organizations (PPO) and National Point of Service (NPOS) networks are very similar. Both offer broad, nationwide networks. Both have out of network coverage options. Both give you the freedom to see any doctor without a referral. NPOS plans do not typically require that you go through a primary care doctor for a referral.
Balance billing can be a concern with these networks as the broadness of the network allows for more overlap with providers that are not in network, even at the same hospitals or doctor offices. However balance billing is a hot button issue and there legislation in the works right now to put a stop to balance billing.
PPO and NPOS Pros and Cons
PPO and NPOS Pros
- Large, nationwide networks
- Out of network coverage options
PPO and NPOS Cons
- Large, broad networks cost more money
- Balance billing is a possibility
The No Network option: Reference Based Pricing
Reference based pricing is an idea that has been gaining traction over the past view years. The basics of RBP is that there is NO network. You go to any provider that you want, and the insurance company pays a the provider a percent of what Medicare pays for that service. The insurance company usually pays more than Medicare, 130-170%.
Read more about RBP here: https://ga-health-insurance.com/reference-based-pricing-in-georgia-what-do-employers-need-to-know/
Which Network is Best?
This is a great question and not one with a straightforward answer. Reference Based Pricing has a lot of benefits for the consumer, but providers push back against it as it pays them less. Kaiser’s integrated care model drives successful treatment, but it offers less options. NPOS and PPO networks give you freedom of choice, but they cost more.
The idea network will vary person to person. It depends on what is most important to you and what is available in your area. If you live in Georgia, you should give us a call! Whether it is individual, family or group health insurance, we can help you compare all the options and find the best health insurance coverage for your needs.