Question About Health Insurance UPDATED INFO

Updated on October 29, 2015
E.B. asks from Littleton, CO
17 answers

I'm wondering if anyone can help me understand this. My dh pays for good medical insurance through his employer.

I don't really understand the whole "network" thing. I know that we need to make sure that our doctor is "in our network". I guess it's sort of a large company that manages the insurance companies and an insurance company administrators can choose which network they want to belong to? So we don't pay the network, we pay our particular insurance company which then probably pays the network? I'm guessing that there are a few large networks and many insurance companies that join in the network, both big and small.

Anyway, recently I learned that our insurance company changed networks. I found this out while standing at the receptionist's desk at the doctor's office. The receptionist informed me that they were no longer in our network.

This is a huge shock to me, as this means I'll have to pay in cash, up front, and then request a reimbursement at out-of-network rates from our insurance company. My dh and I are discussing how to handle this, as the doctor in question is part of a large clinic where all of dd's specialists are.

My question is: when an insurance company changes networks, are the paying members informed of such a major turn of events? We did not receive any information about a change in network. Is this something that we should have known about and checked before going to a doctor? Is it up to us to monitor which network our insurance company is with, week to week, or monthly or what? When the apartment complex where we rent an apartment was sold to a different company, we received a very nice letter from both the selling and buying companies, telling us that our rent would remain the same, we could expect certain changes like an improvement to the pool area etc., and telling us the name of the new management company and the new name to write rent checks to from then on. I would think that health insurance would do the same - it seems much more important.

Did we miss something or is this just how health insurance works now? What would you do?

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So What Happened?

Thank you, everyone, for the insightful and informative responses! I checked with our doctors' clinic. What they told me was that our insurance company (which has not changed) used to be with United HealthCare. Now they're with something called First Health. And the doctors are not in network with First Health. So our insurance company (I'll call it ABCD) is still the same. Our premiums are the same. But it's the United HealthCare and First Health part that have changed. So am I correct in thinking that our insurance company is ABCD, and the network is First Health (and the former network was United HealthCare), and the doctors' clinic does not work with any insurance company, whether its ABCD, or WXYZ, as long as that insurance company is affiliated with First Health? I'm sorry to be so dense about this stuff!

More Answers

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M.D.

answers from Pittsburgh on

Julie S's response is good. I would add only that when my doctor decided not to participate in my health insurance network anymore, the doctor's office informed me, not the insurance. This makes sense, because the doctor's office can look in their system and see which of their patients is with the insurance that they decided not to accept, and send out the letters. Your insurance does not keep track of what doctors you see, so they do not do this, in my experience. So, I would lay the blame for the lack of advance notice in your doctor's lap, not your insurance company.

That said, I suggest you call your insurance company directly and find out what the out of network fee is. It might be reasonable, but it might not (my insurance provides NO out of network coverage at all, which means I would have to pay 100% of the bill). You can also call your doctor's office, let them know that since they are no longer in network, you'd like to be referred to someone who is. My doctor, with whom I had a good relationship, was sorry to see me go, but completely understood and recommended a few doctors in my network that she thought would be a good fit.

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T.S.

answers from Washington DC on

It's not the insurance that changed networks.
The network is the list of doctors that participate with your insurance carrier. Your DOCTOR is no longer in your network. I would have expected the practice to send you something letting you know that they no longer participate in your insurance network so that you could decide whether to find new providers.
My advice would be to ask for referals to specialists that are in your network. That's why you have insurance. There's no reason to pay out of pocket when you're also paying insurance.

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G.♣.

answers from Springfield on

My husband works for the State of Illinois and we live in Springfield (lots of state workers), so any changes like that are usually big news for us. We almost lost our Primary Care Physicians because the state signed a contract with a different insurance company that didn't use Springfield Clinic (which is huge)! And this was the summer before our oldest started kindergarten ... ahhhhhh!!!!

We ended up not having that change, but we have had changes in our deductible for prescriptions. It's not fun going to the pharmacy and expecting a $20 (or less) co-pay, only to be told that we have not yet met the $150 deductible for the child who never needs prescriptions.

Insurance companies do usually notify you of changes, but my husband is notorious for not reading relevant emails or just tossing flyers in the garbage. Ug! I've had to call the insurance company before to clarify. But it stinks when it hits you unexpectedly.

What you need to do is call the insurance company and find out what you need to do. You may need to get all new doctors. You may not. You might be able to keep some specialists if that specialty isn't already covered in their current network of doctors. But you're going to have to do some research to find these things out.

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M.M.

answers from Boston on

Ok ...I work in insurance...a major 5 star HMO (sorry to brag but I had to get that in)....Do not blame the insurance carrier for this. Insurance companies do not change networks; providers do - the doctors choose to participate in the plan or not (aka to be or not to be in network). My company notifies its members when a particular provider they have used in the past 12 months is terminating their contract. On occasion, rare as it may be, a pcp will submit a specially approved (by the pcp's medical director not the hmo) referral which we , the insurance company/HMO will honor and thus pay the claim(yes, we do pay claims). You can always call your insurer's customer relations dept to confirm your benefits and who your contracted providers are (please dont tell me they outsource to india orsomewhere like that).
good luck

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D.D.

answers from Boston on

I work for an insurance company and can tell you that usually we don't send notification unless its a large hospital that hasn't signed to be in network. The reason is to allow people using that hospital and providers who have practice rights at that facility a chance to set up alternative care without impacting their health.

In your case the practice should have let you know that they were no longer on your plan and it would have been nice if they had done that before you were standing there for your appointment. The way it works with most practices is that if one doctor drops then all doctors drop however you may want to call each of the specialists your daughter uses to see if they are still contracted with your insurance.

Personally I selected the hospital I wanted to use and then selected physicians with practice rights at that facility so if you need to get new innetwork doctors that might be the way to go. Or you could ask your physician for recommendations of doctors and then check to see if they are in your network.

Changes in insurance and networks are ongoing so once you have the knowledge you can guide your healthcare from there.

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J.S.

answers from St. Louis on

All a network is is the group of providers that have signed contracts with that insurance company for a level of service. When you look at your EOB you will see a billed amount and an accepted amount. That is the providers contractual write down. What that means is the contract states that for this procedure we will pay you X dollars. Already negotiated, works perfectly.

Out of network they have no contract so they have to try to claw down that billed amount. Since that costs and they will not get it down to a contract rate they charge you a higher percentage, deductible, or copay depending on your plan.

All saying they are no longer in network means is the insurance company offered them too low a rate and they refused to sign a contract. No, your insurance company does not have to comb through who you usually see and point out they didn't not sign on this year.

Contracts are generally signed in December and go into effect in January. They do update a list of providers via paper and online. A network is not a group that gets together and says we are a network it is just who signs a contract.

Sorry if I rambled a bit, just wanted to make sure I got it all in there. Just an FYI I am an accountant in a medical billing office, I wasn't making this stuff up.

Oh, one last thing ask who in the clinic is in network. It may be just that one doctor.

Looking at your what happened it sounds like your husband's company self insures. They changed companies who service their employees which means your insurance company did change. That should have been spelled out in the packet you are given during enrollment.

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D.B.

answers from Boston on

I think it would help to understand that your insurance company didn't actually change networks - what changed is that your doctor is no longer a member of the insurer's network. That can happen for a lot of reasons - sometimes the doctor just doesn't want to accept the fee/reimbursement requirements of an insurer, and sometimes a doctor no longer has admitting privileges at the hospitals in the group. For example, we have a health insurance plan in New England started by a number of the big Boston hospitals (Mass General, Brigham & Women's Hospital, and so on). If an individual practitioner is no longer associated with any of those hospitals, he/she is no longer in the network because there's no place to send his patients. And if a doctor (r physical therapist or psychiatrist or whatever) no longer wants to limit his/her fees to those allowed by the insurance company, they can't stay in the network.

An example you may be familiar with is when you have a car accident, and the insurance company gives you a choice of certain body shops you can use. You can choose freely among those, but if you go to someone else not in that "network", your coverage doesn't apply. These body shops have agreed to charge certain prices for certain work, and not go above that price limit. In exchange, the insurance company says, "We'll put you on our list for all our policy holders, and if they need the services you provide, they can choose you. You'll get guaranteed customers by charging only a pre-approved price for each type of repair."

Ostensibly, these networks keep your costs down. You aren't paying extra for this.

So the insurance company isn't actually paying a network - it's not like there's a master network like an internet service provider! The network is just all the practices that are members. You are in the network - the doctor's office no longer is.

Because these changes in medical coverage happen all the time, the insurer can't possibly notify every single policy holder who might be a patient or have been a patient of that practitioner at some point in the past. That would be logistically and financially impossible. They publish a printed list probably twice a year, and you can check on line for a list of participating "in network" providers. When you booked your appointment, the receptionist should have asked you what insurance coverage/plan you had, and should have let you know that they were not longer accepting it. It's the doctor who is motivated to get paid, either by the insurer or the patient. In my view, it was the job of the practice to verify your appointment when you made it. If you made it six months before the practice dropped out of the network, then the office should have written a letter to everyone in their file who also had an appointment booked to say, essentially, "According to our records, you are insured by XYZ insurer. Please be advised that we no longer accept this insurance and are not part of XYZ's network. Therefore, if you wish to stay with our practice, you will be responsible for all costs. If you have changed insurance coverage/companies, please contact our office to verify that we accept your new policy." So they fell down on the job and didn't tell you until you arrived, which was a bit unfair and very inconvenient.

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M.R.

answers from Washington DC on

Please re-read Diane B's good explanation. The "network" is the term for all the doctors who participate with your insurance company -- the network is not a separate entity or some third party. It's just a term for the list of doctors whom your insurance covers. Think of "in-network" doctors as those whom your insurance covers, period. Out of network doctors are those who are not on your insurance company's rolls, so if you use them, you pay a boatload more money. Check carefully-- your insurer may not pay anything if you use an out-of-network provider, or it may pay something. It certainly won't repay you 100 percent.

It sounds as if this particular doctor has left the insurance company network. This would mean that the company no longer pays any of this doctor's bills if you go there. You need to find a new doctor who participates with this insurer.

Unfortunately, insurance companies leave it up to the patient to figure this stuff out, and may or may not choose to notify you that a doctor you use is dropping out of the insurer's network (or being dropped). It is up to you to monitor whether any doctor (or dentist or optometrist) is covered by your insurance. I'm surprised your doctor's office did not notify you that they were no longer working with your insurance company, but I don't think there is any regulation saying they, or the insurer, has to notify you; I know plenty of folks who have turned up at a doctor's office to find that their doctor was no longer on their insurance, sadly.

Go on your insurance company's web site and there should be lists of doctors who are in their network. Are other doctors at this same clinic in the insurer's network? Are the specialists in the network? Do you have to have a referral from a primary care physician before you can see a specialist, or can you go directly to a specialist--do you know? That's vital to know, because if you need a referral and don't have one, the specialist can turn you away. Yet some plans do allow patients to go directly to a specialist without referral (our new plan allows it which is a big change from our old insurance coverage).

I did get notified by our insurance company just yesterday that my longtime ob/gyn was no longer in their network as of two weeks ago, and that I would need to find a new doctor if I wanted insurance to cover it. Here's the clincher: I phoned my ob/gyn immediately because I had JUST been on the phone with them yesterday morning before seeing that letter and they didn't say anything. Turns out the insurance company letter was dead wrong -- the doctor is still on that insurance, but some computer or lackey spit out that form letter in error, so now the doctor has lots of patients calling confused and upset. So...check and check again when you hear from the insurers about anything.

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M.S.

answers from Washington DC on

Just want to add that if you stay with the out of network providers, your payments may not go toward your deductible. You may have a separate out of network deductible. Double check on this. Also, a good source for info is the HR dept.

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S.C.

answers from Kansas City on

Diane B and some of the others are correct - this isn't your insurance company, this is the doctor's office, no longer accepting your insurance. I had the same thing happen once, and it wasn't indicative of any changes in my insurance. I just had to find a new doctor. Especially horrible since you have so many specialists you deal with :( But to answer your question, yes, this is very typical of the medical industry in general.

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N.B.

answers from Oklahoma City on

I guess with this company I'd make sure to ask, when you make the appointments, if they still take the one you have. That way you will go in and not be surprised when you get there.

I wouldn't have had the money to pay outright for this. That would stink.

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S.B.

answers from Houston on

This isn't the insurance company, this is your doctor's office. Insurance companies have networks and doctors decide if they want to accept that insurance companies payment fees. Sounds like your doctor opted out of the insurance network. Generally, the doctor's office will let you know that they are no longer accepting that particular insurance. I would discuss this with the doctor's office.

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J.B.

answers from Boston on

Odd...United HealthCare IS an insurer (I'm very familiar with them as they have been my insurer and a client). Perhaps your insurance company previously aligned itself with UHC's network and then moved to affiliating itself to First Health, which is a provider network?

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C.B.

answers from San Francisco on

I know that when GD's pediatrician changed networks, his office advised us so we could decide to either find another doctor or change our insurance to one within his new network. I don't know what legal responsibilities they have, but I would be very upset with my doctor if they didn't advise of the change. Also, hubby's employer should also have been advised that the carrier changed networks and provided a list of doctors in the new network.

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D.N.

answers from Chicago on

Unfortunately, Julie is right. They do not have to send you a notice and a lot do not. For us, my doctor's office sent us a letter when insurance we had through Medicaid when I was laid off was no longer going to be accepted. And if my doctor's office (with a major hospital) is not in network with the insurance I have through work, I do get a notice from my insurance along with a suggestion of a nearby doctor. So some do, but not required.

For your rent and change in ownership, they are required to provide you notice of change of ownership and whom to pay rent.

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R..

answers from San Antonio on

Oh and last time I checked in Texas if you are in an HMO (not a PPO or a POS) the doctor cannot see you if they are not in your network even if you pay cash out of pocket. Now this might have changed with Obamacare. But be sure to double check, because our pediatrician suddenly no longer took our insurance...and my son had a follow up appointment and they could not see him even if I paid cash. (I was so upset!!)

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J.K.

answers from Wausau on

"Network" is a verb in this case, not a noun. To "network" means "to work with". It is not a new thing and nothing has changed.

Doctors and hospitals can choose to accept insurance plans from a particular company, or not. That is what is meant by 'network'. It means the insurance company and provider have an agreement. You pay your insurance premium, the insurance company pays the provider as stipulated by your plan.

Your medical provider can drop or add insurance companies and plans. They may or may not let people know when they do it, so you have to stay on top of making sure that your doctor(s) accept your insurance plan.

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