No matter the type of health insurance plan, the vast majority use a network of contracted providers that must accept the insurance company’s pre-determined negotiated rate as payment in full. This is true whether an individual is covered through an employer group health plan or a Medicare supplement policy. An exception to the rule is many Arizona short term health insurance plans which allow the policyholder to see any licensed provider they like.
Understanding your particular network of providers is important if the goal is to avoid unexpected medical bills. Every insurance company has a provider search tool on their website. After locating your provider of choice using the search tool it is important to call them to verify that they are still in-network, as directories may change from one day to the next.
When calling a provider to verify if they are in-network many people will ask if the provider accepts their insurance plan. This is the wrong question to ask! Just because they “accept” most or all insurance plans does not necessarily mean that they are in-network. The question to ask is if they are in-network and specify the insurance company AND plan. Also, never assume that all the doctors in a particular practice or location are all in-network.
This past January of 2022 legislation went into effect regarding surprise medical billing that offers more protection to the consumer in emergency situations. A common issue many consumers face in this regard relates to ambulances and air ambulances, many of which have no in-network relationships with providers. It is best to ask your insurer to negotiate directly with the ambulance service, as they have the expertise in this arena.
Another common issue consumers face is out-of-network charges from emergency room doctors. Again, thanks to legislation passed in January there are new protections in place to help the consumer in these emergency situations. It is always best to have the insurance company negotiate on your behalf with out-of-network providers. If the insurer will not negotiate on your behalf, it is recommended that you file an appeal with the insurer.
