Surprised to Find Out Primary Care Dr. No Longer Is in Network...

Updated on August 06, 2011
B.P. asks from Bedminster, NJ
4 answers

Hi Moms,

I just had 2 appts at my primary care physician who had previously been in network (for the last 5 years) but I did not verify before going these last 2 times. At the time of the appt they verified that I still had the same insurance, which is Blue Cross and I said yes. At no time did they tell me that they were no longer in network. I have zero out of network coverage and I just got my EOB saying that the doctor is not covered. What am I supposed to do?? I don't think I should have to pay anything since no one, not my insurance or my doctor told me that they were no longer covered.

What can I do next?

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So What Happened?

I am going to call both the insurance company and the doctor's office. I understand that the insurance can't contact everyone everytime their doctor falls out of network. Considering I have been a patient there for over 5 years and I pay 700 dollars a month for insurance for the 3 of us I do not want to do any kind of payment plan unless he is willing to accept 5 dollars. Now I know why I was the only patient in the office.

I spoke to the office this morning and said that I would not be charged at all. They are working on getting back into network and don't want to lose patients. It's nice to be treated fairly.

More Answers


answers from New York on

I work for a huge insurance company so here's the 411. Your insurance company will not notify you when a doctor drops out of their network. Most insurance companies keep a database on their website with their providers listed. Doctors and join and drop out of networks at any time so you really do have to keep on top of things.

I'd say that you should check with the insurance company to make sure the bill was submitted correctly with the proper dr's name listed. Doctor's use billing services to submit their paperwork and the billing services can make mistakes. If the paperwork was submitted correctly then ask the insurance rep to check to make sure that the provider really is no longer in the network. Ask them what date the dr dropped from the network. If it was close to your appointment then possibly the office staff hadn't been informed yet.

Once you have this information contact the doctor's office. If they submitted something incorrectly ask them to submit a corrected billing. If they are truly out of the network ask why you were not informed of thi when you made the appointments since they verified your insurance info. You can certainly ask for a discount on services due to the lack of info which they may or may not give.

The part you may not want to hear is that you do have to pay for the billing. You signed paperwork at the dr's office saying that you are responsible for payment for services rendered. If you choose not to pay they can turn the billing over to a collection service and ding your credit report for this. If you can not afford to pay the billing in full set up a payment plan with the dr's office of say $5-$10 per month to pay it off. As long as you are making payments they can not send you to collections.

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answers from Springfield on

I would call both. Be very nice about it, but be persistent. Ask the insurance company why your doctor is no longer covered by them, when this happened, did they make an attempt to notify you and tell you that you needed to change doctors. Call the doctor's office. Let them know that when your insurance was verified, no one mentioned the fact that your doctors does not accept that insurance.

Be kind, be persistent. At the very least, maybe you can get the insurance company to cover one of the visits and the doctors office to cover the other. It sounds like they both dropped the ball.

2 moms found this helpful


answers from Washington DC on

I would be miffed...I don't like to assume anything's July and usually changes are made in January. So when they asked you about your insurance at that time they should have told you that they were no longer taking BC.....I would go back to the Dr.s office and tell them that it was THEIR responsibility to NOTIFY YOU PRIOR to the appointment that they no longer accepted BC...

On the other side - I would pay at least half of the visit as they did see you and take care of you...but I would make them suck up the other half since they failed to notify you that there was a change..


1 mom found this helpful


answers from Savannah on

Interesting. A couple times in the past 2 years (PERHAPS once a year?) I got a letter from Aetna insurance saying that Cook Childrens would not be in network due to negotiations or something to that effect. So I say you SHOULD have been notified. And if the dr's office knew you still had the same insurance, they should have mentioned it to you, even if just to let you know. I remember I called my pediatrician after both times and the office chick there said not to worry, they would be in network, there was just "back and forth" over rates that would be accepted. (Aetna wanted to pay them less, the doctors said no, but it was like the biggest provider in the area and they didn't want to say no and lose all Aetna customers). I did double check with the insurance agency first though and got the go-ahead from them, before showing up at the office. No problems.
I wouldn't freak out, you can ask specifically, as of what day, the doctor became out of network because you may have visited on one day, the contract been over a few days later, and the billing department submitted it to your insurance a few days after that. It's possible that is what happened (last October our health insurance changed from Aetna to United but I wasn't aware of it, I expected it to change when we moved to the new job in November.....we saw our local doctors for checkups in October before moving....middle of December, I get bills for all these doctor visits because we were no longer with Aetna. Well that was 2 months ago, but a month before I expected our insurance changed! I was concerned. But then I called the NEW insurance agency and they said that they had taken over, just earlier than I expected, and they covered all the bills). I'm sure it can be worked out. Do discuss it with both parties until it's resolved. (Insurance is your best bet, the doctors are pretty limited, but may be able to help). Diane had a point with billing: I used to see a female doctor at a certain office, and one day I got something saying she wasn't in network. I phoned the doctor's office, and they said they mistakenly put in her name, but they were supposed to bill in the name of the male doctor who ran the clinic. They changed that up and it went through fine.
DO NOT just "not" pay it. I would try to fight it.
But don't just "pay half and make them suck up the other half"----for crying out loud! That WILL hurt your credit. You do have to pay if you lose (in which case I'd be upset and look for a new doctor and a new agency if possible), but like Diane said: if you pay just a little bit every month and don't miss a payment, you won't be turned over to the collectors or hurt your credit. I learned that after having a hospitalization 8 years ago (uninsured back then) and owing thousands....I just payed $50/month because that's what I was able to do, and they couldn't "hurt" me for it.

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