Navigating Out-of-Network Care: A Guide to Reimbursements for Employees

Educating employees about reimbursements ensures they feel supported wherever they seek care.

While HMOs often provide access to an extensive network of accredited providers, there are times when employees may need to seek care outside this network. Understanding how to navigate out-of-network reimbursements ensures employees can still access quality care without undue stress. For SMEs, educating your workforce about this process is essential to maintaining satisfaction and trust in your health benefits program.

Why Employees May Need Out-of-Network Care

Out-of-network care may be necessary when an accredited provider isn’t available nearby, in emergencies, or when employees prefer a specific specialist not covered by the HMO network. Ensuring they understand the reimbursement process empowers them to make informed decisions.

Steps to Navigate Out-of-Network Reimbursements

1. Explain What’s Covered:
   Clearly communicate which services are eligible for reimbursement, such as consultations, diagnostics, and treatments with non-accredited providers.

2. Provide a Simple Checklist:
   Create a guide detailing the documents needed for reimbursement, such as official receipts, medical certificates, and prescriptions.

3. Educate on Claim Limits:
   Inform employees about the reimbursement limits and how they relate to the Maximum Benefit Limit (MBL) in their health plan.

4. Streamline the Submission Process:
   Use digital tools like Purple Cow’s SmilePH app, which allows employees to file claims online, track their status, and reduce paperwork.

5. Encourage Pre-Approval When Possible:
   In non-emergency situations, suggest that employees request pre-approval for out-of-network care to confirm reimbursement eligibility.

6. Set Expectations for Timelines:
   Be transparent about how long the reimbursement process typically takes, so employees know when to expect their funds.

Benefits of Educating Employees on Reimbursements

Providing clarity on out-of-network reimbursements ensures employees feel supported, even when seeking care outside the HMO network. This proactive approach builds trust and minimizes confusion, enhancing overall satisfaction with your health benefits program.

Support Employees Wherever They Seek Care

Ask Purple Cow about out-of-network reimbursement options and provide your team with seamless healthcare solutions, even for non-accredited providers.