Health insurance policies are widely maligned for their complexity and lack of transparency. From complex terminologies to endless pages of fine print, many people tend to overlook the details they should be aware of. With medical insurance now mandatory in both Dubai and Abu Dhabi, a majority of UAE residents will be forced to learn more about health insurance. Unfortunately for many people, it is only when they file a claim that they start to learn about their medical benefits – or the lack thereof.
One of the crucial factors in any kind of health plan is the provider network. It should play a significant role in deciding how suitable a health insurance policy is for you.
What is a provider network?
A provider network is a list of doctors, healthcare providers, hospitals, pharmacies, diagnostic centres, speciality centres and polyclinics, that a health insurance company has contracted with in order to provide medical care to its members. All these providers are referred to as “in-network providers” and ones that aren’t contracted are known as “out-of-network providers”. Every health insurance policy has a specific list of medical facilities in its provider network.
Why is the provider network important?
When a client needs to use the policy when getting admitted to a hospital or consulting a medical professional, an “in-network” provider does not have to be paid upfront and instead, the bills are settled directly by the health insurance company. Consider this as a tri-party arrangement where the payments are made by the insurance company directly to the healthcare provider on behalf of the client. The client agrees to pay a fixed premium regularly while the actual costs (depending on other terms and conditions) are settled by the insurance company. This is popularly known as a cashless facility or direct billing. Such an arrangement is very convenient during emergencies when coming up with cash is the last thing that family members want to worry about. By merely presenting one’s medical insurance card, the patient is admitted, treated and discharged without any hassle.
When the medical care is provided by an “out-of-network” facility, the patient ends up paying all expenses upfront to the hospital or clinic, and must then go through the process for getting reimbursed by their insurance company.
So how is the provider network list created?
Quite simply, the insurance company contracts with hospitals, doctors and other healthcare providers to treat their customers at a discounted rate. The provider relationship contracts could be direct or through third party administrators such as Nextcare or Mednet (also known as TPAs). It’s a win-win for all. Providers get more patients since they are in the network list, insurers are able to give more options to their members and hence improve their customer base, and clients get better terms for medical treatment on a cashless basis.
How is the provider network kept up-to-date?
Most residents in the UAE do not even know that the network list is subject to change! When you buy a medical insurance policy, the table of benefits will stay the same for the duration of the policy. However, the provider network changes frequently. While, in practice, most insurers avoid removing major hospitals from their networks as they realize it is a selling point for many customers – many insurers update the list on a monthly or quarterly basis. This means that a hospital you frequently visit may no longer be covered by your policy at any time. On the other hand, a great hospital or clinic might be added to your provider list!
The health insurance network is updated by adding or removing new medical providers, or including exclusions on specific doctors, specialties or facilities. Unfortunately, it is common to find outdated network lists with doctors and clinics who are no longer in business. Moreover, most insurers send the entire network list whenever there is an update, so it is hard to figure out what changes have been made. All this leads to unnecessary inconvenience to policyholder when they are actually in need of their healthcare benefits.
Most insurance companies and brokers in the UAE do not regularly share updates with their customers. Whether it is a company medical policy or a family one, it is crucial to make sure that all policyholders have easy access to an up-to-date provider network list. This is especially important when there is a medical emergency. What if the patient is admitted to an out-of-network hospital when the family members assumed it to be in-network? It could create financial complications for the family. It may also mean that the patient is exposed to higher charges for the treatment.
Some insurance companies keep an updated list of the provider network on their websites. Others simply do not bother sharing updates with their customers. As an HR manager, you should always ask your insurance provider how they plan to keep you up to date about network changes.
For example, at Bayzat, we make it as easy as opening the Bayzat Benefits app. Each month, we update the network list so that our users can see the most recent facilities in their network through our intuitive map. Not to mention that all our users also get automated notifications whenever a hospital or clinic is added or removed from their provider network.
Find a solution that works for you so that you are not caught off guard when you can least afford to.