Q: Can a health plan make a patient travel outside a particular service area (say 40 miles away) to receive care from an exclusively contracted provider?
A: There are two overriding factors that will determine the answer to this complicated situation. The first is state law. It is advisable to reference state law to determine if there are specific coverage requirements and any provisions relating to provider exclusivity.
The second is the benefit plan. The benefit plan is the driver in determining what services are available from contracted versus non-contracted providers. For instance, HMO coverage stipulations may differ from a PPO plan.
Two Forum experts answered this question together: Dawn Boyd, director, managed care contracting, The Godbey Group, Irving, Texas, and Dan McAfee, senior managing director, payor contracting and reimbursement strategy, The Godbey Group.