Depends on the insurer, doesn't it?
Honestly, I have no idea which insurer I'm "in" with and whom I'm "out" with for an individual patient. My job is to see patients, irrespective of whose insurance they hold.
But insurers, well, it matters hugely to them who patients see. After all, they have pre-negotiated amounts they are willing to pay for services with those physicians. And for the most part, this is OK - consumers sign up for these cheaper plans knowing they might be inconvenienced from time to time.
Until doctors don't agree to insurers' rates and refuse to accept terms negotiated by insurers. Doctors sometimes decide not to be "in-network" with a particular insurer.
But sometimes, those doctors are emergency physicians or radiologists - all of 'em - for a particular hospital. So patients in a HMO plan sometimes have to go to the closest hospital for emergent care. They then receive bills from these "out-of-network" physicians. They become enraged because the ER doctor and/or radiologists bill them when the insurer has "promised" to pay for their healthcare! "How dare you!" they scream. Doctors become the bad guy.
But who's the "bad guy?" The doctor or the insurer? Doesn't the insurer have a responsibility to their patient members to at least provide adequate physician panels for coverage of their members? Do people really think doctors should work for free?
Inadequate healthcare networks is becoming an increasingly important issue and the efforts of the Texas Medical Association is a must-read as they fight to place the onus of providing adequate physician networks to the insurer and restore the doctor-patient relationship:
HMOs promise their enrollees that they will provide prepaid health care for a premium. However, they often fail to provide an adequate network of primary care physicians in their plans, leaving enrollees with unexpected medical expenses. A number of legislators and their staff have been victims of an unexpected charge and are blaming the one they receive their bill from – the physician.The Texas Medical Association clearly has their eye on the ball here and other states' medical societies should take note.
At the heart of the inadequate networks issue is deciphering who is ultimately responsible for medical expenses incurred out of network. Insurance companies don’t want to be held accountable for creating adequate networks or informing their enrollees about adequacy of their plans. In essence, they want to keep breaking their promise to enrollees and surprise them with unexpected expenses, while continuing to post record profits and pay their senior executives millions in salaries and bonuses.
I belong to a PPO plan. All 4 hospital systems participate but in 2 of them the anesthesiologists, radiologists and ED docs do not participate. One of those two hospitals is where I have been a frequent flier when all the urology stuff started and was ongoing.
My plan pays non ppo providers 75%. I can see where they would prefer to not be in network. Although...I guess the promise is more pts if they participate?
I called my ins company stating that I have chosen a participating hospital but I can't choose the doctors in those specialties.
They said they will pay the additional 15% so they get reimbursed 90% of the UCR charges. However I have to remind them every time.
I hope my reg docs don't drop our plan. As far as being a pt...the turn around payment times are quick to us or the providers and I am glad they pay 75% when I choose out of network.
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