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Figuring out if your Doctor is in-network can be a CHALLENGE

We here at Texas Medical Plans, continuously hear from our clients that they have difficulty verifying whether or not their doctor is in-network with their health insurance provider. We hear things like: “I found my doctor on the health insurance company’s website, but the doctor’s office says they do not take it” or “My doctor is in-network but the hospital that they are preforming my procedure at is out-of-network” or our favorite “My doctor’s office says they do not take Obamacare” (NOTE: All the health insurance plans offered now, the health insurance plans that keep you from having to pay a tax penalty, are “Obamacare”. This means that the plans now meet the regulations set forth by the Affordable Care Act (ACA)).

Changes in the health care industry have people confused, misinformed, and FRUSTRATED! I know you may not want to hear this but WE UNDERSTAND! I could write a book about all of the difficulties I have had with my own health insurance. Yes, you would think that a health insurance agent would not have insurance issues, but that is not the nature of the individual health insurance industry these days.

Just one example: I took to my daughter to a doctor, whom I confirmed was in-network with my health insurance carrier and the doctor’s office prior to the visit. I paid the specialist copay as usual. I later received a bill for the office visit. Keep in mind this was an initial visit to examine my daughter and discuss treatment options. No testing was done in this visit. We saw the doctor in his office, which was in a building right next to the hospital, but it was billed out-patient. Apparently, because we did not see the doctor in the hospital it was out-patient and went towards the deductible verses the specialist copay as previously confirmed.

I think that if we had seen the doctor in the hospital as in-patient that we would have seen an additional bill from the hospital/facility. A lot of times you will see a doctor that is in-network, but the facility/hospital the doctor performed the procedure in was out-of-network. The only explanation I can offer you is that they are separate entities and they have separate contracts with different health insurance companies.

So, what does this all mean for you? You have to do your best to be educated and proactive. We suggest the following:

  1. Know your health insurance plan. Know if you have copays, coinsurance, what your deductible is and your out-of-pocket maximum. Do you have an HMO or a PPO network? Did you know that an HMO network requires prior authorization from your primary doctor before you can see a specialist? Health insurance can be confusing! The health insurance agents at Texas Medical Plans do our best to make health insurance simple for our clients.
  1. Check with your insurance provider. Call your health insurance company to confirm a doctor, facility, lab, anesthesiologist, the person that pokes their head in for 5 minutes to check on you while you are in the hospital, etc. is in-network. Keep detailed notes about your conversation with the representative, including who you spoke to, their department, get a reference number if possible, the more information you can record the better. Get pre-authorization when possible. If you have an upcoming procedure find out how each party (doctor, facility, etc.) codes it on their bills and check those codes with your insurance company. Does that procedure go towards your deductible and can they give you an idea of how much it will cost you? This keeps you from being surprised and also helps you to check the bill later for errors.
  1. Communicate with your doctor! Ask your doctor questions like are you in-network. How is this billed? What codes do you use when billing? Is this preventative? Sometimes we see where a client goes in for their physical (covered 100% under preventative care) but then they ask about a medical issue . . . now the doctor is addressing an issue and the visit is no longer preventative. Every doctor is different though. The list of questions can be endless and it really depends on the situation. The health insurance agents here at Texas Medical Plans encourage our clients to have open communication with their doctors and get an idea of what their billing process looks like.
  1. Check your Explanation of Benefits (EOB) and your bill. Compare your EOB and bill to see if they look correct. There are so many medical codes out there now that we constantly see errors in the way people are billed and errors in how health insurance companies process claims. Everyone is doing their best to process things correctly, but nothing is perfect. If you don’t understand something, ask your doctor’s billing department and ask your health insurance carrier. At the end of the day it is your money being spent so do your best to know exactly what it is being spent on.

It can seem like a full time job staying on top of your health insurance. Do your best and remember there are health insurance agents like us here at Texas Medical Plans that can help you to understand your health insurance and how it can work for you.

Courtney Mecklenburg