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Ask This, Not That When it Comes to Out-of-Network Doctors

By Lisa Zamosky

Out Of Network Costs

A few weeks back I wrote a blog post about health care bills and four common, costly mistakes people make. A reader of this blog who says he develops employee health and wellness benefits packages for a living posted a comment about an additional common mistake I didn’t mention in my post, and one that I agree is important to mention.

Here’s what the reader, Daniel, had to say:

The four issues you discuss make perfect sense and I often [talk about] these during employee meetings. Please allow me to point out one more error that I often see: If you belong to a PPO, which allows you freedom of choice, don’t believe it means going to whomever you want to. If your physician or hospital is not a contracted provider, your liability can be substantial, so be careful.

The Key is in the Question

Even though a PPO plan gives you the freedom to seek care outside of your insurer’s network, most people understand that doing so costs more money than seeing a doctor who holds a contract with your health plan, and who has agreed to treat patients at negotiated rates.

You can check the network status of a doctor or hospital with your insurance company – most allow you to access their list of providers online or distribute benefit booklets containing the information – but to be safe, you should call the provider directly to confirm that they are, indeed, in-network with your insurance company.

The key to receiving care from a provider that is contracted with your insurance company is in the questions you ask.

The wrong question: Do you accept my insurance?

As Daniel correctly points out, many physicians will tell you that they accept payments from insurance companies, but that doesn’t mean they have a contractual obligation to provide the discount you’ll receive from in-network doctors. In the end, you’ll pay more for the visit.

What’s more, Kaiser Health News recently reported on a disturbing trend in which consumers are being hit with even higher out-of-network charges. This is due to insurance companies having altered the way they calculate what they will reimburse for out-of-network care. In some cases, insurers have begun to pay physicians and hospitals Medicare rates, which are considerably lower than the historically paid usual and customary charges.

The right question: Are you contracted with my insurance company, or are you considered an in-network provider?

What you want to determine is whether the doctor holds a legal contract with your insurance company that requires him or her to provide medical services at specific, agreed-upon rates.

Your turn: Have you failed to ask the right question when seeking medical care and paid for it in the end? Please share your experiences in the comments section below.

Photo: Thinkstock

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