The Value of Medical Networks with Limited Health Care Plans

Greg Rudisill

Aug 3, 2009

The Value of Medical Networks with Limited Health Care Plans

In today’s evolving health care industry, using a medical network in conjunction with a limited health care plan is often a good option for members seeking extra value through network discounts. With these medical networks, members may receive discounts on both insured and non-insured services, and quality assurance support is available for any provider issue. Many challenges tend to surround some medical networks with limited health care plans.

One significant challenge occurs when provider offices aren’t accustomed to the limited medical benefit design. As a result, the provider offices typically don’t know what services are covered, when the member’s insured benefits are exhausted, what the reimbursement will be, how their fees will be repriced by the network, or how and where to file the claim, and what to collect from the member. 

An extensive amount of supervision and communication is essential to any efficient, successful process. One such problem that continues to exist with some medical networks is the lack of proper oversight. Without proper oversight by the carrier, or their network administrator, medical networks can add confusion to both providers and members. And if there is not proper communication between medical networks and provider offices, then providers may not understand the unique limited health care benefits and administration elements.

In addition to these potential challenges, many providers may not understand how their fees will be repriced by the network administrator or what to charge the member for their portion of the bill. This situation often leads to providers charging the member for the entire visit up front and requiring the member to file the claim. Once the claim is repriced by the network and the claim is paid, the member may discover that the provider owes them money.

Members may find it difficult to collect from the provider, or they may not even make the effort to contact their provider to recapture overpayments. Ultimately, this process can lead to dissatisfied members and providers, which could result in members canceling their limited health care plan and providers resigning from the network.

Practical solutions

Establishing enhanced alternatives could lead to improved understanding by both members and providers, and offer extra value for both parties. For instance, members that utilized the relatively new medical concierge approach have indicated improvements in communication, understanding, acceptance and satisfaction. This unique concept is essentially a situation whereby patients call into a specialized customer care group to locate providers that accept their limited medical plan and provide discounts.

The medical concierge approach simplifies the process for the patient. Concierges can even assist the patient in securing an appointment with a provider. Regardless of whether the concierge schedules the appointment, the concierge will contact the provider’s office (process referred to as onboarding) to provide education on the member’s plan, to provide eligibility verification, to explain to the provider’s office what their responsibilities will be once the patient comes into their office for treatment, and to confirm that the provider is still active in the plan’s respective network. 

The onboarding process is vital to improving provider understanding and acceptance of the limited medical benefits prior to the member’s office visit. Provider onboarding has numerous benefits, such as reducing the number of steps in the registration process, eliminating problems with providers not accepting the plan and overall member dissatisfaction at the provider’s office.

Additional advantages of the medical concierge approach for the provider and member include, providing real time eligibility verification, explanation of benefits and claims repricing. With these alternatives, there would be less confusion for both the member and provider. And members would only pay the portion they owe at the time they check out of the provider’s office. In addition to these options, repricing letters are usually sent to providers and members after the process to improve member satisfaction and understanding of the savings. The repricing letters explain the network saving and direct the members to communicate any questions or concerns back to the concierge unit or plan administrator.

Another service typically included in the medical concierge approach is referred to as health care mediation and billing services. Health care mediation provides an additional level of value to members that go out of the network for care, or have an out of pocket bill that is too large to pay. Health care mediation helps eliminate member dissatisfaction at the provider’s office and prevent problems with providers not accepting the plan. The goal of mediation is to prevent conflicts before they occur, and reduce the risk and cost of escalation.

Health care mediation offers other advantages including, negotiating with providers and health care facilities when a member goes to the closest facility for emergency treatment to discover that the facility wasn’t included in the program’s medical network. The medical concierge obtains the member’s permission to negotiate on their behalf to reduce the charges. And if the bill is too large for the member to pay, the concierge will attempt to arrange an acceptable payment plan between the medical facility, provider and the member. All parties benefit from this approach.

Clearly, there will always be challenges associated with some medical networks; however, many new alternatives are available to increase communication and satisfaction for the members and providers. With the growing number of medical networks with LHC plans, it is important to note the benefits and how each one would impact the end consumer.

Greg RudisillGreg Rudisill is the Senior Vice President of Strategic Partnerships for Careington International Corporation. He brings more than three decades of experience in employee benefits to Careington, specifically in managed health care and the group-directed eye care market. In his current role as Vice President of Strategic Partnerships, Greg is responsible for developing relationships with managed care companies, insurance carriers, third party administrators and with broker/consultant organizations. Greg Rudisill can be reached at, or (800) 441-0380, ext. 2102.

Careington International Corporation is a licensed Discount Medical Plan Organization. Dedicated to improving the health and well-being of individuals, Careington International Corporation's health and wellness solutions are designed to complement traditional health insurance and provide substantial savings for under-insured or uninsured individuals. Careington combines its flagship non-insurance discount plans with insurance plans administered through its affiliate, Core Five Solutions, Inc., to create cost-effective solutions that improve the affordability and accessibility of quality health care.

For more information about Careington’s proprietary medical network and discount health plans, please visit, or our affiliate Core Five Solutions