Which policy requires patients to use in-network providers for lower costs?

Which policy requires patients to use in-network providers for lower costs?

• A. Prospective Utilization Review
• B. Network Restrictions
• C. Utilization Management (UM)
• D. Indemnity Plan (Fee-for-Service)

Answer: (B)

The idea being tested is how plans steer costs by directing patients to in-network providers. Network restrictions set up a contracted network of providers and require members to use those in-network providers to receive lower costs, thanks to negotiated discounts. Using in-network providers typically results in lower copays, deductibles, or coinsurance, while out-of-network services are often reimbursed at higher rates or not covered, making the in-network choice financially advantageous. Prospective utilization review involves pre-approval of services to ensure medical necessity, not enforcing network usage. Utilization management is the broader process of reviewing care for appropriateness and efficiency, which can include in-network considerations but isn’t defined by network use alone. An indemnity plan funds services on a fee-for-service basis with freedom to choose any provider, usually with less emphasis on in-network discounts and higher potential costs.

The idea being tested is how plans steer costs by directing patients to in-network providers. Network restrictions set up a contracted network of providers and require members to use those in-network providers to receive lower costs, thanks to negotiated discounts. Using in-network providers typically results in lower copays, deductibles, or coinsurance, while out-of-network services are often reimbursed at higher rates or not covered, making the in-network choice financially advantageous.

Prospective utilization review involves pre-approval of services to ensure medical necessity, not enforcing network usage. Utilization management is the broader process of reviewing care for appropriateness and efficiency, which can include in-network considerations but isn’t defined by network use alone. An indemnity plan funds services on a fee-for-service basis with freedom to choose any provider, usually with less emphasis on in-network discounts and higher potential costs.