Negotiations between health plans and healthcare providers can be unsettling for members whose access to care may be impacted or feel uncertain.
It’s natural to have questions about what’s happening during a provider negotiation and how it may affect your care. For easy reference, we’ve assembled answers to some of the most frequently asked questions about providers, networks, facilities, and costs in the blog post below.
Questions about providers and networks
To learn more about how Premera approaches negotiations with providers and how we prioritize controlling healthcare costs for our members, you can visit our negotiations landing page here.
If you still have questions after reviewing the answers below, call the phone number on the back of your Premera ID card and a member of our customer service team can provide further information and guidance on the best next steps for your healthcare.
Questions about providers and networks
I received a letter that my provider will be out of network. What happens now?
You can continue to receive care from your current provider through the end of their contract. In some cases, members with a chronic condition or who are in the midst of treatment may continue to receive care while paying in-network rates after their provider’s contract ends. This is called continuity of care.
Your letter will provide more information on who to contact to learn how you can continue your present course of treatment with your current provider. It will also provide information on how to find a new provider.
What if I am currently receiving care and my provider is no longer in-network?
You may be able to establish continuity of care with your current provider at the current in-network benefit level for up to 90 days if you are receiving treatment for a covered service or for a complex or chronic medical condition. Such conditions include pregnancy or scheduled nonelective surgery.
You can contact customer service at the number on the back of your Premera ID card for more information about this process.
What do “in-network” and “out-of-network” mean? Can I change my network?
An in-network provider currently has a contract with Premera, and when you see them, you are typically only responsible for cost shares and deductibles. An out-of-network provider doesn’t have a contract with Premera, and you may be responsible for all charges, including cost shares and deductibles.
You can learn more about the types of networks that health plans offer by visiting our Provider Networks page.
How do I know if this negotiation impacts my current provider?
If you have received care from a provider whose contract may be ending, you will receive a letter 30 days before that contract end date, as required by state regulations. We will also post information about current provider negotiations on our Healthsource blog. You can use our Find a Doctor tool to find information about your primary care provider’s associated facilities. Or call us at the phone number on the back on your Premera ID card.
Do I need to find a new provider right away?
In most cases, no. We’re required to send you the notification of termination 30 days before the provider contract ends. In the majority of cases, Premera is able to reach an agreement with the provider before the contract ends. If a new agreement is reached, we will notify you that your provider is remaining in network.
You can also visit our Healthsource page for updates on provider contract negotiations.
How do I find a new provider?
To find a new provider in your network, sign into your account on Premera.com. Under Find Care, search the Find a Doctor tool.
If you need to find a new, in-network primary care provider, consider Kinwell primary care. Kinwell offers high-quality care just for Premera members in Washington. Same-day or next-day appointments are available in-person or virtually. Find out more at kinwellhealth.com.
Questions about costs
If you’re negotiating for a better rate, why are my costs still so high?
There are several factors that affect what you may pay for a visit to a provider. If you see a provider that isn’t in your network, the amount we pay (the reimbursement rate) may be lower, meaning you’ll have a larger amount that you must pay out of your pocket.
If you have a plan with a deductible and haven’t met your annual deductible, you may pay the difference between the negotiated contract rate Premera pays the provider and what’s left of the bill.
In general, we’re finding that healthcare systems bill health insurance plans more to make up for the lesser amount they receive for Medicaid and Medicare reimbursements. In other words, employer sponsored health plans subsidize other lower paying types of plans.
I’ve heard about bonus payments that providers can get. What are those?
Most providers are paid a ‘fee for service,’ meaning the more services they provide, the more pay they receive. This often led to unnecessary, and costly, services given to members.
Many healthcare systems now participate in performance contracts. These value-based contracts offer ‘bonus’ payments to providers when they meet certain quality metrics. These goals are set together between the health plan and the healthcare system in their contracts. When those metrics are met, the healthcare system may receive additional dollars for that can range from $1M to $20M or more. That’s in addition to the reimbursement rates in their contracts.
How does Premera spend my premium dollars?
Premera is a not-for-profit health insurance provider. We are required by law to spend at least 80 cents of every premium dollar directly on the care of members. If we do not meet that threshold, we refund the money back to members, either through rebates or lower premiums.
In an average year, Premera spends 90 cents of every dollar we receive in premiums on our members’ claims. After that, 8 cents goes to commissions and administrative expenses, such as salaries of employees and improvements to the care delivery system, and 2 cents goes to taxes. Premium rates may increase due to higher claims expenses, which we saw immediately after the pandemic ended. Our profit margin is 1-3% in a typical year.
What type of increases are providers demanding? Can you tell me more about the negotiations?
Specific details, including financial discussions, are confidential. What is important to note is that every healthcare system is asking for increases, some as high as 30%. We take those requests seriously. Our goal is to reach an agreement that fairly compensates the healthcare system and ensures our members have access to quality care at affordable prices.
Will Premera customers incur increased costs due to higher rates at other health systems?
Premera works diligently with our provider partners to reach agreements that provide reasonable reimbursement rates and ensure our members access to affordable, quality care. Costs for different health systems differ for various reasons, including location, cost of doing business, and other factors. It is a false assumption that members will pay more if they go to another care provider or facility.
While difficult, these negotiations allow us to look for shared opportunities to reduce costs. We serve as your advocate during these discussions. It is important to remember that Premera’s role is to be good stewards of our customer’s dollars. That’s why we are dedicated to working with our healthcare system partners to find reasonable solutions that address rising healthcare costs.
