How We Build Our Networks
Florida Health Care Plans (FHCP) provider networks include hospitals, primary
care physicians, specialists, urgent care centers, imaging centers, laboratories,
home health agencies, pharmacies, and many other services and health care
providers. Our directories, both online and paper, are important resources
to help you find any type of health care provider who participates in
your specific health insurance plan.
FHCP considers a number of factors when selecting providers to participate
in our provider networks:
Availability of Provider
FHCP works to ensure we have the right number of network health care providers
in the right locations for our members. At least once per year we review
our networks by looking at the location of our network health care providers
compared to where our members live. We also look at the number of health
care providers compared to the number of members to ensure we have enough
providers available. Primary care physicians, hospitals, urgent care centers,
and the most commonly used specialists, including behavioral health specialists,
are included in this review.
Access to Provider
FHCP also considers standards for access to care such as guidelines issued
by the Center for Medicare and Medicaid Service (CMS) and any state regulations
related to health care provider networks related to timeliness of appointment
and other factors. In addition to monitoring member complaints regarding
access to providers, FHCP also reviews access to primary care physicians
and behavioral health specialists on an annual basis. If we determine
that members do not have appropriate access to health care providers to
meet our members’ needs in a timely manner, we work to add more
providers to the network. Doctors and other health care practitioners
selected for FHCP’s network go through a thorough credentialing
process. The credentialing process is a way to verify the qualifications
of doctors and other health care providers. The process includes checking
education and training, licensure, board certification, malpractice claims
history, and other background information that applies to the provider’s
specialty. Doctors are reevaluated at least every three years. Providers
in our Medicare Directory must also be participating in good standing
FHCP considers other efficiency, effectiveness, and outcomes measurements
when enough information is available about a doctor. For example, how
primary care physicians perform on nationally recognized measurements
such as Healthcare Effectiveness Data Information Set (HEDIS) and whether
patients receive appropriate health screenings for breast cancer, colorectal
cancer, cervical cancer, etc.
FHCP currently does not utilize any specific quality measures other than
credentialing standards to evaluate doctors and hospitals participating
in our networks.
In order to participate in FHCP’s network, health care providers
and hospitals must be willing to agree to a negotiated rate. These negotiated
rates are one advantage of having health insurance because you usually
pay less for the services you receive when you visit a health care provider
in FHCP’s network. In some cases, FHCP looks for health care providers
who are willing to agree to reimbursement arrangements that reward them
for meeting certain performance standards or outcome metrics for their patients.
FHCP currently does not utilize any other cost measures to evaluate doctors
or hospitals participating in our networks.
FHCP makes a priority of contracting with doctors who have admitting privileges
at our participating network hospitals. This means the doctor has a relationship
with the hospital and is allowed to admit patients there. This helps members
go to a hospital that is in their network when hospitalization is needed.
If you use a hospital for non-emergency care that is not in FHCP’s
network, FHCP may pay less or may not pay for the services you receive.
FHCP also considers member complaints received about specific doctors,
hospitals, and other health care providers when deciding whether to continue
a provider’s contract with our network. FHCP regularly conducts
surveys regarding patient experience with primary care and specialty doctors
who participate in our network.
FHCP currently does not utilize any other patient experience measures to
evaluate doctors or hospitals participating in our networks.