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Health Reform 101

with Lisa Zamosky

WebMD helps readers understand their health insurance and the new health care reform law. The Affordable Care Act is bringing sweeping changes to American health care. Lisa Zamosky is here to help you navigate the health care maze and understand how these changes affect you.


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Thursday, February 23, 2012

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

Posted by: Lisa Zamosky at 2:40 pm


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