Using In-network Physicians and Other Care Providers Reduces Costs

Humana PPO members who seek care and services from participating physicians and care providers may be able to keep their out-of-pocket costs more affordable compared to those who use noncontracted providers. Since our affiliated providers are often in the position of making recommendations to their patients regarding such decisions, Humana urges physicians and office staff to attempt to steer patients to in-network providers. In addition, members should understand that any balance paid to a nonparticipating provider does not count toward their deductible.

Alan Wheatley, a director in Humana's consulting practice who works on payment structures for nonparticipating providers, noted that members would benefit by using in-network hospitals, clinics and physicians. For example, members whose coinsurance is 20 percent may end up paying not only that amount, but also any difference between the amount charged by the nonparticipating provider and Humana's maximum allowable fee. Following is a hypothetical example:

A member enrolled in a 90/60 PPO plan is covered for 90 percent of the contracted amount for in-network providers. The out-of-network benefit covers 60 percent of the maximum allowable fee. For example, if an in-network provider has billed charges of $8,600, assuming Humana's contracted rate is $6,000, the member's responsibility would be $600. In an out-of-network situation, with the same billed charge of $8,600, assuming Humana’s maximum allowable fee is the same as Humana's participating contracted rate of $6,000, the member's responsibility is $2,400 (40 percent of $6,000) + $2,600 (the difference between the billed charges and our maximum allowable fee). Total member responsibility in this out-of-network setting is $5,000. Out-of-network (nonparticipating) physician bills for associated services are also subject to the same maximum allowable fee provisions.

Members or providers who are uncertain about a particular provider's network status are encouraged to use the Physician Finder Plus feature on www.humana.com. This feature provides a listing of participating physicians, other care providers and facilities. Members who do not use the Internet can call the Humana customer service number listed on their ID card to determine whether a physician or facility is in the Humana network. Or, members can call their physician or other care provider directly to confirm participating/nonparticipating status.