What do you mean my doctor is not accepted in your network, I asked if they accept my insurance before I went!

 

I read a post in the NAHU agents blog today that said “…Always add the caveat that the client needs to confirm with the doctor/hospital that their insurance is in fact accepted, ideally in an e-mail.”  (NAHU (nahu.org) is the National Association of Health Underwriters and is the professional organization for people, like me,  who work in health insurance and employee benefits.)

 
OK back to the subject. Yes it is important to ask if your physician “accepts” your  health insurance, but it is even more important to ask  “Are you a contracted provider?”

 

The majority of medical providers will say yes if you ask if they accept your insurance. (unless it is Medicare and they may say they do not accept Medicare patients.) This does not mean they will be “in network” and thus be subject to the contracts that limit what the physician may charge you.

 

Here are some terms you need be aware of:

Contracted Provider: A medical provider who has agreed to a contract to provide services for a medical plan that you are a currently covered by.

Balance Billing:  If you use a “non contracted” provider they may accept what your insurance pays and then bill you for the “balance” which is whatever they feel remains of the bill.

Out of Network: This refers to a provider that is not contracted with the network of medical providers you have an agreement with. They may tell you they “accept” your medical insurance, but they do not have to accept any limits from your insurance, nor PPO network.

 

I frequently hear from clients who used an “In Network” physician, were admitted to an “In Network” hospital and still received an “out of network bill.” “How did that happen?”

 

Just because a facility like a hospital is contracted does  not mean that everybody in that hospital is a member of that contract.

 
This happens most frequently in these two scenarios:

1. A person goes to the hospital for a surgery and has to be sedated. The anesthesiologist is not under any membership contract and bills as an out of network provider. 

You can request only member providers prior to surgery.

2. A woman goes to the hospital for child birth and during the birth it becomes an emergency. After the birth she discovers that the specialists that saved her life and her baby were not member providers and she is responsible for the whole bill.

In most cases this is negotiable with your insurance company as it was beyond your control.

 
Insurance is a contract between you and your insurance company to help you afford expenses you both agree are covered. The contract does not agree to pay for anything that might happen to you. This means that you need to know what everybody has agreed to and that you need somebody to  be on your side and help you understand. That would be your insurance agent.

 
I will close this with a blatant plug for qualified insurance agents. Generally speaking a “navigator” (Google it) isn’t going to represent you when you really need it. If you are looking for somebody really qualified to help you go to NAHU.org and use the “find an agent” application.

 
Or, of course, you can always contact us at 602-381-9900 or bweaver@focusbenefits.com.


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