By NextBestFitNarrow networks and out-of-network surprises
Plans cover only listed providers; directories are often wrong ('ghost networks'). Seeing an out-of-network doctor, sometimes without knowing it, can mean large bills.
Evidence
- Among insured adults, problems include difficulty finding in-network providers and prior-authorization delays; 58% had at least one coverage problem in a year.Sources: KFF (2023)
Who's affected
- People with ongoing or specialist care needs: Needed specialists and therapists are often out of network.
- Health insurers, brokers, and their shareholders: Narrow networks let insurers offer lower premiums.
- Hospitals and specialist groups with high private prices: Out-of-network providers can bill high charges.
Under your mix of paths
- Many separate payers each negotiating networks
- Providers that profit from staying out of network
Related costs
Open questions
- Should networks exist at all, or should any licensed provider be able to see any patient?
Solution paths (2)
Open a path for what it fixes, what it creates or worsens, who gains and who loses, precedents, and how it connects to other paths. See all paths as a decision tree.
Under one payer or all-payer rates, any licensed provider can see any patient at the standard rate.
- +Narrow networks and out-of-network surprises
- +About $1 trillion a year in administrative cost
- −Raises spending or loosens control over it
- −Medical errors and poor care coordination
Keep networks but set strict distance and wait standards, with fines for 'ghost' directory listings.
- +Narrow networks and out-of-network surprises
- −Requires difficult enforcement
Also addressed by paths for other problems
Every provider bills the same payer, so there are no networks to be in or out of.
Standard benefits and mostly uniform provider rates reduce differences between competing plans.
Allowing patients to choose any provider preserves provider choice within the public payer.