Get the facts: Why isn’t the doctor I want to see in my health plan’s network?

• Choosing in-network care providers is one of the most effective ways to manage your healthcare costs and avoid unexpected bills.
• Understanding how your health insurer develops and maintains its provider network can help you feel more confident in your ability to get the care you need from in-network doctors and hospitals.
• When building their networks, health insurers focus not just on including a large number of providers but also on ensuring their members will have access to high-quality, affordable care.
• If one of your providers leaves your health plan’s network, it’s understandable if you feel concerned or stressed, but you still have options to get the care you need, and resources are available to help you transition smoothly to a new provider. 

Searching for the right doctor for you or your family can be a frustrating experience. And if you finally find one who seems like the perfect fit but she's not in your insurer’s network, it can make an already complicated healthcare experience feel even harder. Perhaps the only thing worse is when a doctor you’ve seen for many years leaves your health plan’s network because contract negotiations fell apart.

At the center of all of this is a simple question many people ask: Why can’t I see the doctor I want?

Understanding how your health insurer develops and maintains its provider network can help you feel more confident in your ability to get the care you need from in-network doctors and hospitals. And choosing to stay in the network for your care is one of the best ways to get the most value out of your health plan.

A doctor might not be included in your health plan’s network for a variety of reasons, but the simplest answer to this question is that your health plan either decided not to establish a contract with that doctor or was unable to do so through negotiations.

Health insurers are heavily regulated at both the federal and state level. That means they’re required to follow government rules and regulations about many aspects of how they operate their businesses, including how they build their network of care providers.

• The federal government’s network adequacy standards require health insurers to include a minimum number of physicians and care facilities in their network.
• Those standards apply to all types of doctors and care facilities, including hospitals, outpatient clinics, primary care doctors and specialists such as cardiologists and rheumatologists.
• Health insurers are required to meet these standards in all markets where they sell health plans.
• Failing to meet the government’s minimum threshold for in-network providers can lead to severe repercussions for health insurers, including being forced to close certain health plans.

In addition to meeting the government’s standards, health insurers also focus on building a network that’s appealing to consumers. That’s because they know that people like having the flexibility to choose from a large number of doctors and hospitals close to home when they need care. In fact, a strong network is one of the most important things employers and consumers look for when evaluating health insurance options.

To build that kind of network, health insurers focus not just on including a large number of providers but also on ensuring their members will have access to high-quality, affordable care.

• They’re more likely to establish contracts with doctors and hospitals that have a proven track record of delivering quality outcomes for their patients.
• Doctors and hospitals that have earned positive patient reviews and strong reputations in their markets are also desirable additions to an insurer’s network.

At UnitedHealthcare, we’ve developed one of the largest care provider networks in the country, with more than 1.7 million physicians and care professionals and over 7,000 hospitals and care facilities included nationwide. We’ve established such a large network because we want all our members to have access to quality care when and where they need it – and without having to travel far.

If a doctor you want to see or hospital you want to use for an upcoming procedure or surgery isn’t in your health plan’s network, it’s understandable if you feel frustrated. These tips can help you find an alternative care provider:

• Visit your health plan’s member portal or mobile app and check out the section dedicated to the provider network. There you can use a variety of search tools to look for providers in your network who provide the type of care you need.
• Tools like UnitedHealthcare’s Smart Choice are designed to make this process easier by helping you compare providers based on what matters to you, like the gender of the care provider, the languages the provider speaks, and the availability of evening and weekend appointments. The tool displays a score reflecting which providers most closely match your search criteria. You can also use Smart Choice to compare the average total costs of your care for various providers in your plan’s network, helping you save money on the care you need.
• You can also call your health plan at the number on your health plan ID card. A member services representative can answer questions about your plan’s network of providers and help you find a provider who would be a good fit for your needs. Some plans will even schedule your appointment for you.

When health insurers add a doctor or hospital to their networks, they establish a contract that outlines the payment rates the doctor or hospital will receive as well as a variety of other agreements about how the two entities will work together. Typically, those contracts are effective for several years. When the contract termination date is approaching, the insurer and the provider will begin negotiations to determine if the contract needs to be updated before it’s renewed.

Negotiations between health insurers and providers are extremely common and usually straightforward. At UnitedHealthcare, because we have so many care providers in our network, we negotiate about 2,000 contracts in an average year, and the vast majority of those negotiations are successful. We negotiate new contract terms with the care provider and agree to new payment rates without any controversy, public attention or disruption in care for our members. We know our members value stability in their access to care providers, so we make every effort to reach this positive outcome every time we negotiate with a provider.

In some cases, however, health insurers and care providers are not able to reach an agreement that’s satisfactory for both parties. When this occurs, payment rates are usually at the root of the dispute, with the provider demanding to be paid higher rates than the insurer is willing to pay. And that dispute occurs because, in this situation, the provider’s goal differs from the insurer’s goal.

• Care providers make more money when they deliver more care and also when they get paid higher rates for that care. So they’re incentivized to pursue higher reimbursement rates from insurers.
• Insurers’ goal, on the other hand, is to make care as affordable as possible for the people enrolled in their plans as well as their employer customers. One of the best ways to do that is to ensure the rates they pay care providers are fair and competitive. If insurers agreed to providers’ demands for higher rates, their members would pay higher out-of-pocket costs, and self-insured employers would have to absorb higher healthcare costs. Those employers pay the cost of their employees’ claims themselves, so higher reimbursement rates to providers have a direct impact on their bottom line and could eventually lead to higher premiums as well. About 67% of people with employer-sponsored insurance are enrolled in self-insured plans.

If these sorts of payment disputes can’t be resolved through negotiations, the provider will leave the insurer’s network after the current contract expires.  

If one of your providers leaves your health plan’s network, it’s understandable if you feel concerned or stressed – especially if you’ve built a long-term relationship with that provider. The following tips can help you figure out your next steps so you can continue to get the care you need and, if necessary, transition smoothly to a new provider:

• Be aware that the termination of your provider’s contract with your health plan might not be the end of the story. When a contract terminates, the insurer and care provider will often continue negotiations in the following months, and in many cases, an agreement is eventually reached, bringing the provider back into the network. So if you don’t have an urgent need to see your doctor or schedule a surgery or procedure at the hospital in question, it’s not a bad idea to simply wait to see how things progress.
• If you’re pregnant or in active treatment for a serious condition such as cancer, call your health plan to confirm if you’re eligible for what’s known as continuity of care. If eligible, you can continue to see your current provider at in-network rates for a set period of time.
• Keep a close eye on your mailbox. When the end date of a provider’s contract is approaching, health plans send letters to their members to ensure they’re aware of the potential change in the network, the date when that change goes into effect, as well as the alternative care options that are available to them.
• Explore the other hospitals and doctors in your plan’s network. Check out the providers section of your plan’s member website or mobile app, or give your plan a call to speak with a member services representative who can assist you.

Choosing in-network care is one of the most effective ways to manage your healthcare costs and avoid unexpected bills. Taking time to understand your options – and using the tools and support available – can help you get the care you need with more confidence and fewer surprises.