Does this doctor accept your health insurance?
It would seem logical that once you have health insurance you could visit your local doctor office and have that visit covered by your plan. Unfortunately, in California it is not that easy. Not all doctors or physician groups accept all health insurance plans. Not all hospitals accept all health insurance plans either.
Contracted doctors and hospitals
The obstacle in matching your health insurance to a doctor is that health insurance companies contract with physician groups and hospitals. These contracts include negotiated prices for a variety of procedures, tests and office visits. Because California prohibits hospitals from directly hiring doctors, the hospitals contract with physician groups which they may or may not have an investment in.
Negotiated reimbursement
If a doctor in private practice, a physician group made up of several doctors or a hospital doesn’t like the negotiated prices or reimbursement offered by the health insurance company for different services, they don’t have to enter into a contract with the company and accept their insurance company’s members. The exception is that emergency room care is covered by all health insurance regardless of which hospital operates the E.R. However, any follow up care will need to be through your insurance company’s in-network providers.
Out of network providers can be expensive
While there are a few exceptions like Kaiser, most doctors and hospitals will treat you on an out-of-network basis. This means that your out-of-pocket expenses may not accrue as fast to meeting your plans deductible. Usually you have to meet twice your plan’s deductible amount, if there is one, with an out-of-network provider before the insurance coinsurance kicks in. In addition, your health insurance won’t cover the “no charge” preventive office visits or copayment office visit amount if you see an out-of-network provider.
Is my doctor an in-network provider?
One of my first recommendations to people looking for new health insurance or wanting to change companies is to find which insurance plan their current doctor accepts. It seems like this would be a simple course of action but for individual health insurance plans it can be a challenge.
I recently had a client that was looking at two different insurance companies for health insurance and wanted to make sure his current family’s physicians would accept the insurance. Both Anthem Blue Cross and Health Net yielded inconclusive results using their provider finder website application. In both instances, it was nearly impossible to get any reliable results unless you were a member of the plan. This raises the question, “If I am not a member, how do I compare and find a doctors between the different insurance plans?”
Which plans are accepted?
Why purchase a health insurance plan if your preferred doctor, physician group, or hospital isn’t covered? After fruitless time spent trying to coax an answer out of the internet provider search queries and too much time waiting on hold with Health Net, I went right to the physician group the doctors were affiliated with, UC Davis Health System. While UC Davis indicated they would accept Anthem Blue Cross individual PPO plans, Health Net was still murky. They listed two Health Net plans that Select and Fit, but no Advantage or Value plan as being accepted.
Conflicting information
Because this might have been an outdated web page, I called UC Davis direct. One woman told me they don’t accept Health Net individual PPO plans. On a second call to confirm the Anthem Blue Cross, a different woman said UC Davis accepts all PPO plans. Upon further inquiry, UC Davis accepts all PPO plans but their doctors may not be in the insurance provider’s network. If you go out of network for anything but an emergency room visit you are opening yourself to higher costs, procedures that may not be covered and out-of-pocket expenses that accumulate at a lower rate to meeting your deductible compared to in-network services you pay for. The value of your health insurance is cut in half when you go out-of-network.
In-network equals full covered benefits
If you select a physician group that “accepts all PPO plans” but aren’t in-network providers for your chosen health insurance plan you will not receive all the covered benefits that your health insurance plan offers. The bureaucracies within the insurance companies, physician groups and hospitals can be virtually impossible to navigate and get a straight answer as I found out.
Variety of plan types
With the mandate that everyone must purchase health insurance in 2014, excluding Medicaid eligible, keeping your current doctor or finding a new one in-network of the insurance plan is important. It is very frustrating to learn your doctor doesn’t accept your selected health insurance plan. There are many different types of plans that physician groups and hospitals may accept. All of these variations may be listed on their website.
- HMO: Health Maintenance Organizations
- PPO: Preferred Physician Organizations
- ACO: Accountable Care Organizations
- Individual and Family Plans: HMO, PPO
- Small and Large Group Plans
- Medicare Advantage Plans
Web search and phone calls
Another layer of confusion can be that only specific plans within a category from an insurance company are accepted. When in doubt and the insurance company’s provider search is inconclusive, you’ll have to start making phone calls. My fear is that with the state health insurance exchanges coming on line with a whole other set of plans, the frustration of matching your doctor to plan might be exacerbated.