Who should I contact? I need help from policy experts...

[Phentex]

Today it was confirmed by my insurance company that they have only one way of knowing if a doctor or facility is in network and that is if the doctor or facility confirms that they are. If a doctor decides to drop your insurance plan, the doctor must notify the insurance company. Otherwise, they stay on the in-network provider list indefinitely; the same list used by your insurance company. Yes, the patient can call and ask if the doctor is in network. But what happens if they say yes they are and then send in a claim and the insurance company says they are out of network? The patient has to pay as out of network.

What happens if the doctor gets an authorization from the insurance company with approved services but then the claim is shown to be out of network and denied? The patient has to spend hours on the phone trying to figure out why.

When you select a plan at healthcare.gov, they encourage you to research the doctors you want to see or the medications you may be taking to see if those things are in network. But you are looking at a website that may be completely out of date. You can call the insurance company and they are looking at the same website you are so they say yes it's in network and send you an ID card with that doctor's name on it. You can then call the doctor and they may or may not be in network. You can also do the reverse; call doctor and they say yes, but insurance company says no. One doctor's office said oh you need to call your insurance company to make sure. Endless loop of nobody able to confirm.

Today a very patient rep from the insurance company explained that they are frustrated as well and have the same discussion at every staff meeting. There is no one at the company who can confirm if the doctor is actually in network or not. I was put on 2 conference calls, one with the facility where my care took place with both the billing person AND the doctor and the insurance rep told them they would have to use the provider portal to confirm they are in network. Second call was to the overall billing company and we were put on hold and then disconnected.

Meanwhile I was looking at MY personal insurance portal. I could see the doctor's name and facility listed as on my care team. I could see that they were listed as in network. The insurance agent could not see that. So I asked how it would be possible for the doctor's name to be on my personal page if someone at the insurance company had not put that person's name on there? I mean, if I went down the street to the local voodoo doctor, would THEY also be listed on the care team?

What am I missing? Why isn't there a way to know if a doctor is in your plan or not?

[erronis]

1. And from what I've been reading (see KHN for good examples), you can't trust what they tell you.

Now that I'm in Medicare I don't have to worry as much, and now my problems are accumulating (75+).

So many stories about patients contesting out-of-network charges are rampant. Also many discussions about how to dispute charges are effective - most patients don't try or give up after a first rejection.

First, I think you should make sure you get all communication in writing. Don't take the word of a phone-answerer as what might be honored. Get documentation and authenticated communications.

Personally, I would also record any phone conversations with any insurance companies, etc. I know it might not be admissable in some states but you'll have the recordings for use to back up your own position.

Secondly, find a health care advocate. I haven't had to get one so I don't know where to suggest. Perhaps your state's human services agency may have a list. Look for ombudsmen, perhaps hospital care navigators.

Claims processing is notoriously sloppy - even for the insurance companies and the recipients. Individual charges can take months working their way through the paper handling.

Maybe consider writing a few friendly but accurate and forceful letters to the upper-echelons of the organizations involved. And think about writing some personal comments to local papers.

Organizations like KHN and Propublica as well as others are very receptive to getting individual stories. If it is part of a trend then they are very powerful at getting positive action.

[Phentex]

4. Good ideas....

I had prior authorization noted as in network. I received that by mail. Also could be noted that I saw a different doctor at this facility for a different reason and those claims were processed as in network. In my stack of papers, I have something called a primary insurance benefit summary. This is from the doctor’s office and shows a case number, my info, the insurance info including deductible and limits and co pay. It states authorization and referral required which was sent before I started going there. So someone there must have called or looked at the provider portal to get that info.

In my insanity prior to this, I have considered calling 1000 doctors listed as in network on the insurance website to find out if they are still on the plan. And then looking one year from now to see if it’s changed. It’s mind boggling to me that the insurance company takes no responsibility for information on their website or by phone and the doctor’s office says you have to call your insurance company to verify.

[Rebl2]

2. I have

learned over the years before I choose a new doctor to check to make sure they take my insurance.

[Phentex]

3. That's what I'm talking about...

The doctor’s office will say yes, no, or contact your insurance company. The insurance company might say yes, I see them on the list. But then the claim gets denied for being out of network. The insurance company might say no but the doctor might insist they really are in network. I will not go unless the insurance company says yes. I think that’s true of most people. Now what I don’t understand is getting prior authorization from the insurance company sent in the mail and then the claim being denied for being out of network. I do not have out of network benefits so why would they provide prior authorization with a notation that the plan is in network?

[Rebl2]

5. I think

my first colonoscopy the doctor I had was in network, but he used an anesthesiologist (dr.) who was not. I was not pleased.
I have no idea no idea why they would approve it, then say it was out of network. It’s maddening. I guess every step of the way you have to double check that what they are telling you is true.