Health Insurance in America

Out-of-Network providers

Ensure that all providers and facilities involved in your care are contracted with the network your health insurance plan is contracted with. Don’t make assumptions, actually ask. You should always ask what providers will be performing billable services when having Inpatient or Outpatient surgery, and if they are in-network. For example, just because your doctor is in your network, they sometimes use labs or other third parties during your treatment that are not in your network. If the services you are having performed are not available from a contracted provider, or you can’t wait to make arrangements or would have to travel a great distance, contact your insurance company or administrator and discuss alternatives with them.

If a provider refers you elsewhere for services, always verify that the provider and/or facility you are being referred to is in your network. Asking your original provider or his/her staff is ok, but you should verify with your insurer to be sure. Your doctor and his office may not be aware of all other providers’ network status. If your provider or facility was in-network the last visit, don’t assume they are in-network on THIS visit. Ask the office staff to confirm.

Many plans contain provisions for using an out of network provider or facility in extreme circumstances such as a particular provider type being more than 35 miles away. If you do plan to utilize an out-of-network provider, coordinate with them in advance to determine what they will accept as payment. Understand how your insurance treats out-of-network providers and how they determine the allowable. You might have a real need or desire to go out-of-network. Understand that it is going to cost you more, but do your homework so you minimize the cost, and are not surprised.

If you have concerns, always discuss them with your insurance company.

Preauthorization

You need to be aware of what services require preauthorization under your plan, and verify that it has occurred. Most doctors know how and when to do this, but be sure to verify. Or do the notification yourself. If a service requires preauthorization and you fail to obtain it, then your benefits could be significantly reduced, or there may be no benefit at all.

Occurrences

Know that there may be limits on certain benefits in your plan and understand what they are. Plans have limits on the number of times you can receive a particular treatment, lab, or diagnostic test in a specific period of time. A common limit on dental plans is that fillings are allowed only once on the same tooth every 18 months, and panoramic x-rays are allowed only once every three years. Another example is physical therapy. Your plan may only cover a certain number of visits.

Covered Services

Your provider may tell you a service is covered by your health insurance plan, but it’s up to you to know or verify. Your providers and their staff cannot know all the details of your health insurance plan. There may be certain tests that are specifically excluded under your plan or there may be restrictions on what kind of facilities you may visit. Some health insurance plans only pay for x-rays and other diagnostic testing that is done in a free-standing facility as opposed to a hospital (which is normally much more expensive). Also, some procedures may have only partial coverage. Discuss all your treatment with your providers, and if necessary, with your insurance company or administrator. There may be alternative tests that fall within your coverage that will be less expensive. If your plan will only pay a portion of a covered service or a maximum amount they will pay, you may be able to use cost transparency tools, and other means to shop around to find a less expensive provider.