Newswise — For the average American, having a health insurance card in their wallet provides a sense of health care security. It’s commonly believed that as long as you have a card, you have access to health care.

For some it may be true. But others may be surprised to learn that they could be vulnerable to unanticipated expenses or problems accessing certain physicians. This has some wondering if consumers really know what they’re buying.

“The changing health care environment is being driven by the Affordable Care Act (ACA), which has its benefits such as a young adult being able to stay on their parents’ health insurance until they turn 26,” says Scott Shapiro, MD, president of the Pennsylvania Medical Society. “But we’re finding that as there are positives we enjoy, there are some downsides that should force us to adjust our traditional thinking about insurance coverage.”

According to Dr. Shapiro, as the ACA has enabled more to be insured there have been health business decisions made by insurers which consumers need to pay close attention when purchasing an insurance product.

“Transparency and patient education are necessary steps for consumers more so now than ever before,” Dr. Shapiro says. “Many business decisions within the insurance industry to make an insurance product financially more attractive come with consequences to patients that may surprise them.”

Narrow Networks Impacting Choice

According to Academy Health, a health services research organization based in Washington, D.C., narrow networks are “a cost containment strategy” being used for health insurance plans in which “insurers generally seek to offer lower premiums by limiting the group of providers available to plan enrollees.”

Furthermore, the organization says quality is “not a criterion for exclusion or inclusion in a network.”

“On paper when a consumer is looking at different plans, it sounds like a good deal,” says Robert Rodak, DO, president of the Pennsylvania Academy of Family Physicians. “Insurance plans using narrow networks are often priced lower to make them more attractive to consumers, who often shop based upon the premium price.”

But, Dr. Rodak wonders if consumers really understand that there’s a trade-off. In exchange for that lower cost, consumers accept fewer access options.

His suspicions are confirmed in a June 2015 research project conducted by the Robert Wood Johnson Foundation and the Leonard Davis Institute of Health Economics at the University of Pennsylvania. This study concluded that 41 percent of networks are small or x-small. X-small is defined as including less than 10 percent of office-based practicing physicians in the area, while small narrow networks include between 10 and 25 percent.

“This creates several scenarios that possibly could play out for patients,” says Dr. Rodak. “Imagine a patient who has seen a specific family physician for years suddenly finding out that their doctor isn’t included in their new insurance coverage because of a narrow network. That’s just one possibility.”

‘Surprise Billing’ resulting from narrow networks

Another unanticipated outcome of narrow networks is the possibility of an unexpected bill for health care services, says Christopher Peters, MD, president of Lackawanna County Medical Society located in Dunmore, Pa.

“Narrow networks leave patients more vulnerable to experiencing out-of-network care, which can result in separate billing for that care,” Dr. Peters. “These patients are going to find it more challenging to navigate their way through the health care community because not everyone is going to be in-network. Sooner or later, they’ll end up out-of-network and with potential out-of-pocket costs that they weren’t anticipating.”

In Pennsylvania, the state insurance department is currently looking into the matter and is concerned about access to care and out-of-pocket costs consumers face. A recent letter to Insurance Commissioner Teresa Miller from PAMED’s Dr. Shapiro points out that the first line of defense to protect patients “should be a regulatory framework that fosters adequate networks that provide patients with timely access and choice.”

“’Surprise’ balance billing is an inevitable side-effect of inadequate networks and unfair contracting and potential patient misunderstanding about the insurance products they have purchased,” wrote Dr. Shapiro.

According to a Consumers Report survey, nearly one-third of privately insured Americans have received a bill they weren’t expecting. Periodically, some of these bills come as a result of a hospital visit which may have providers both in- and out-of-network.

Brad Klein, MD, a Willow Grove neurologist and a Pennsylvania Medical Society member, who testified late last year at a hearing led by Pennsylvania Insurance Commissioner, has firsthand experience with being an out-of-network provider. It’s not uncommon for him to accept an emergency call at 3 a.m. to help a patient in a time of need. Out-of-network billing is generally the result of a situation outside of a patient’s or physician’s control.

“We should not put the burden on the patient to decide if they will accept a provider’s care at a time when they are suffering from mental or physical ailments and truly may not have a choice as that provider is the only one available in that community to assist that patient at that time,” he said during the hearing.

Dr. Klein’s story highlights yet another possible scenario that patients are facing as a result of narrow networks.

“A patient may go to a certain hospital because the hospital is in their plan’s network, but that doesn’t always mean all of the physicians connected with that hospital are also part of the plan,” says Dr. Peters. “This is problematic in emergency situations and likely not avoidable, but it can even happen during scheduled care through a hospital. It’s really important for patients to know their plan’s details to navigate care without any unexpected bills.”

Insurance Approvals Can Lead to Care Hassles

Health plans require early approvals for certain medical tests and procedures before they are administered for those services to qualify for insurance coverage. Within the health care insurance industry, this is called prior authorization.

While the process is intended to minimize the overuse of health care services, it often becomes extremely burdensome due to a lack of standardization and transparency in prior authorization requirements.

In Pennsylvania, a bill to reform the prior authorization process has been introduced by State Rep. Marguerite Quinn (R-Bucks) on Feb. 9, 2016.

Rep. Quinn’s bill, House Bill 1657, would increase transparency and consistency in prior authorization criteria among all health insurers resulting in cost savings to the entire health care system. The bill also lessens manual processes and enhances the electronic exchange of information. It would also develop a standard prior authorization form and improve response times for prior authorization determinations.

“Many physician offices spend a tremendous amount of time in communication with insurers to gain approval for a diagnostic test or medication for a patient,” says PAMED’s Dr. Shapiro. “This has become a hot button issue for physicians and patients, and unfortunately many find it frustrating.”

Andrew R. Waxler, MD, FACC, president of the Berks County Medical Society and a member of the Pennsylvania Chapter of the American College of Cardiology, is one of those physicians for which this is a hot button issue.

"This bill is a critical step in the right direction in improving healthcare care - for both patients and doctors,” says Dr. Waxler.

One of those with first-hand experience on how frustrating it can be is Mark Lopatin, MD, a district trustee at PAMED and a practicing rheumatologist in Willow Grove.

In a guest blog on, Dr. Lopatin describes a situation involving a patient who was diagnosed with polymyositis, an autoimmune disease that causes inflammation of muscles and generalized weakness.

With limited options already exhausted, Dr. Lopatin decided to try Rituximab, a drug that’s use is considered off-label.

The patient’s insurer denied authorization, leading Dr. Lopatin to a lengthy appeal process. Fortunately, with time he was able to convince the patient’s insurer to approve using Rituximab.

“Insurers will say that they are not dictating care,” says Dr. Lopatin. “They are simply deciding what they will and will not pay for. But when they decide this on the basis of medical information presented to them, they are essentially practicing medicine on patients they have never seen.”

“There needs to be much better education of patients and transparency as to what insurance policies cover,” says Dr. Lopatin. “Many patients have no idea how their insurance works.”

“If a procedure or medication is denied, the insurance company should be required to provide an explanation other than that it ‘does not meet our guidelines,’” he adds. “A transparent rationale for denial, even if they simply were honest about the cost factor, would go a long way toward alleviating many frustrations.”

Getting empowered through transparency

With greater transparency and consumer empowerment in mind, there are some important questions consumers should ask when purchasing an insurance plan. The Pennsylvania Medical Society recommends patients purchasing insurance plans ask the following:

1. Will I be able to see all of my current doctors?

2. What other doctors are included in my network?

3. Are all the doctors associated with my hospital included?

4. Financially, does this insurance plan work for both my budget and my health?

5. What are my out-of-pocket cost responsibilities including the deductible, co-payments, and co-insurance?

6. What’s covered? Does this plan include dental, vision, and prescription medications?

7. If I am traveling, what level of coverage does this plan carry?

8. If the insurer denies a treatment that my doctor recommends, is there a process for me to dispute the denial?

This news release is brought to you by the Pennsylvania Health News Service Project, consisting of 21 Pennsylvania-based medical and specialty associations and societies. Members of PHNS include Pennsylvania Allergy & Asthma Association, Pennsylvania Dental Association, Pennsylvania Academy of Dermatology & Dermatologic Surgery, Pennsylvania Academy of Ophthalmology, Pennsylvania Academy of Otolaryngology, Pennsylvania Academy of Family Physicians, Pennsylvania American Congress of Obstetricians and Gynecologists, Pennsylvania Chapter of the American College of Cardiology, Pennsylvania Chapter of the American College of Emergency Physicians, Pennsylvania Chapter of the American College of Physicians, Pennsylvania Chapter of the American Academy of Pediatrics, Pennsylvania Medical Society Alliance, Pennsylvania Medical Society, Pennsylvania Neurosurgical Society, Pennsylvania Orthopaedic Society, Pennsylvania Psychiatric Society, Pennsylvania Society of Anesthesiologists, Pennsylvania Society of Gastroenterology, Pennsylvania Society of Oncology & Hematology, Robert H. Ivy Society of Plastic Surgeons, and Urological Association of Pennsylvania. Inquiries about PHNS can be directed to Chuck Moran via the Pennsylvania Medical Society at (717) 558-7820, [email protected], or via Twitter @ChuckMoran7.