Provider Network

The group of healthcare providers, hospitals, and facilities that have contracted with a payer to provide services to the payer's members at negotiated rates.

A provider network is the payer's roster of contracted providers. When a health plan member looks for a doctor, they are looking within the network. If you are in the network, their visit is covered at the in-network benefit level. If you are not, the member pays more or the service may not be covered at all. Provider networks are built and maintained by the payer's network management team. They recruit providers to fill geographic and specialty gaps, negotiate contract terms, credential and enroll providers, and monitor network adequacy to meet regulatory requirements. Networks vary widely between payers and even between different products offered by the same payer. A payer might have a broad PPO network with 50,000 providers and a narrow HMO network with 15,000 providers. Their Medicare Advantage network might be different from their commercial network. Their marketplace (ACA) plan might use a completely different network from their employer-sponsored plans. For credentialing, understanding network structure helps you decide which payers and which products to enroll with. Being in a payer's PPO network does not automatically mean you are in their HMO network. When you credential with a payer, ask which products and networks your enrollment covers. Some payers enroll you in all products simultaneously. Others require separate enrollment for each product line. Network composition affects your patient volume. If a major employer in your area offers UnitedHealthcare, and UHC has two networks — a broad one and a narrow one — the narrow network might have fewer providers and therefore more patients per provider. Being in the narrow network could mean more patient volume than being in the broad network. Networks are not permanent. Payers regularly add and remove providers, restructure networks, and change which products use which networks. Staying current on network changes that affect your practice is an ongoing administrative responsibility.