Wait. So How Do I Find out if a Specialist Is Covered by My Plan?

A THCB reader in Connecticut writes:

“I’m a pretty level headed person. I’ve been following the Healthcare.gov story in the news and figured it was more of the usual partisan stupidity out of Washington. I decided to do my homework before getting too worked up.

I went on to my state exchange and compared the available plans. Gold. Silver. Bronze. All very logical. I spent some time comparing options and found a plan I liked. So far so straightforward. No complaints. No plan shortage in my state.

The problems started when I picked up the phone and attempted to communicate with a living breathing human being. I figured it would be a good idea to confirm that my OBGYN’s practice is covered. To make a long story short, I have a pretty serious pre-existing condition that could hypothetically kill me. My OBGYN is one of the best in the state. Moving to another practice is NOT AN OPTION.

Knowing how the system works, I called my OBGYN’s office and asked them to confirm that my doctor’s plan was covered. Should be a five minute call. No luck. Sorry. They don’t have the information yet. Probably yes. They helpfully suggest I give the health plan a call. Well, that’s logical, I think to myself.  It takes time for new plans to  about the plans to make it through the system. So I take their advice.

I call the health plan involved and politely tell them why I’m calling and what I need to know.  Guess what? They don’t know either.

In fact, they don’t seem to know very much about their plans at all. And they don’t seem to care very much either. The answer is probably no. If the code isn’t listed, it doesn’t exist. I push. Okay, then. Well, the answer is probably yes.  Now I’m starting to really freak out. They want to sell me a plan and they can’t tell me what I’m buying?? What the hell? The woman tells me to call the state health exchange. These plans are their responsibility.

I call the state health exchange. Surprise. Surprise.The woman I speak with doesn’t have an answer either. In fact, she doesn’t seem to understand why I need to know at all. She starts giving me attitude, then tells me to call my health plan. I am stuck in a surreal healthcare system loop.  It takes no less than eight phone calls and conversations with two supervisors before I finally got a definitive answer. I can see my OBGYN. I’ve also come to a terrifying conclusion: nobody knows anything. And if I push, they say what they think I want to hear. I won’t believe that my doctor is actually part of their network until I actually submit a claim and they actually pay it.

This is not how you fix our healthcare system.”

If you have questions about the Affordable Care Act or your buying insurance on the federal state exchanges, drop us a a note. We’ll publish the good submissions.

37 replies »

  1. Just pay your doc in full at the time of service, like any other industry. Afterwards, sort it out between you and your insurance company. If you really want docs to file your claims and administrate your insurance plan, most offices will, but who’s going to pay for the doc’s time, effort, and overhead for overseeing these complex processes? If a practice is savvy, it would much rather collect $50-70 upfront or at the time of service, than dealing with the the bureaucracy of collecting $100-120 through an insurer and patient copays. Besides, you, as a premium-paying customer, have a lot more clout with insurers than a third-party doc . . . that is . . . unless you’ve given up control of your buying power to an employer’s group health plan. You get what you pay for . . .

  2. As providers in Texas we are having this problem too. We are having trouble confirming which plans we are on. The insurance companies don’t have clear paths for us to become providers listed. Some won’t allow us to join as they are by invitation only. We have managed to get or confirm that we are on five marketplace plans. It is hard because there are doctors like us that want to participate but the insurance companies are not making it easy

  3. 6.4 Managers not wishing to select their own team but wishing to participate in the Competition may do so by clicking the auto team-select button during the application process. The computer will select an eligible team at random and details of that selection will be shown on-screen.

  4. And understandably so. The major carriers have a lot more manpower to get their ducks in a row, and the small providers have fewer people to do the work necessary to get everything organized.

  5. I love the dialogue that giving people who allegedly do not have insurance and are desperately pursing it are more important than those who had it and now risk NOT having it because they can’t afford it, AND, the “and” the left dismisses as quickly as flushing a toilet, won’t be allowed access to these alleged subsidies because of the income level those losing insurance have.

    Talk about hypocrisy and sheer disingenousness for a group of Americans the Left has basically decided are more likely NOT to be a partisan support to the supporters of the law, who really is insignificant or inconsequential in America?

    It all depends on which side of the polarized extremists running this country you are for, or more importantly these days, which side you are NOT for.

    You vote for ANY incumbent next Fall, you are part of the problem, and have no right to complain WHEN these incumbents continue to ruin the public.

    Can’t wait to read the partisan attack dogs rip through their leashes!

  6. OB-GYN’s are considered a major specialty and even primary care providers in a number of states. Any change in their participation status to out of network would require prior notice to all affected members.

  7. You’re right, when 1/2 of the government is actively trying to make government fail, initiatives like single payer are impractical. But don’t mistake that to mean governments fundamentally can’t do things. The U.S. Government can’t do things because Republicans are deliberately trying to destroy our government.

  8. What about the family medicine specialists? Those who are going to be challenged to care for the bulk of the public? No contracts have been seen. No fee schedules and companies like United healthcare have de-enrolled thousands of primary care physicians. So what’s wrong with this picture?

  9. Millions were losing their coverage before ACA, with no option. People whose plans are being cancelled now can sign up for a different plan.

    Seriously, I’m glad for the sudden concern, but this situation is vastly better than the one before, where if you became to expensive to insure, you had no option!

  10. Hey, look! Another problem that already existed and people are just now starting to notice.

    FWIW, I face the same problem and I’m shopping on both coveredca.org and the private individual market (i.e. going around to as many different insurance company websites as I can think of). I finally found a simple solution. I asked my doctor (actually the clinic where my doctor works).

  11. “Frankly, if I thought our government could provide the same level of care for all Americans that it provides our Armed Forces and Veterans, I’d be all for it. Sadly, it can’t.”

    Wait, what? The government can’t provide the same level of care it’s already providing? The VA is beyond single payer, it’s basically our own NHS.

  12. “I hear Juan Williams say on Fox”

    There’s a couple without a biased agenda. (sarcasm)

  13. As I continue to warn anyone interested in considering this, don’t pay attention to Obama and his hierarchy in DC just reflexively supporting this law and consequences, but, pay attention to who just reflexively defends and apologizes, insincerely mind you, for these said consequences that are so “inconsequential” and “insignificant”

    I hear Juan Williams say on Fox or any other show he goes on and say those above two words about the MILLIONS of people losing health insurance coverage they wanted to keep, and should, well, I hope those two terms become the real legacy of the Current Occupant of the White House by 2016!!!

    But, he will have his millions telling us even to then how he should be made a saint by the Vatican. On the day he leaves office!!!

  14. Sounds like you’re pretty embittered about not being able to follow a truly free-market process, since you say the ACA is aimed at enslaving people.

    You might consider dropping out of ALL networks. You could set your own prices , and rely just on your own skill and reputation to bring patients to you. Many doctors do this . And then you wouldn’t need to be so bitter.

  15. Shorter version of this blog post: “Wait, you mean Obamacare didn’t magically fix all of the existing problems with our healthcare system??”

  16. “I count myself lucky. I grew up in a military family and spent 20 years in the military myself. As a child I had great care, on active duty I had excellent care, and today I enjoy good care from our Nation’s VA health care system. It’s not the best money can buy, but it is the best taxpayers should be expected to fund.”

    You warn against single pay but extoll VA and military health care – what do you think those systems are? Glad you could depend on the taxpayers for payment of your medical care.

  17. “filled with slavery and high price cost.”

    Slavery, to who – insurance companies?
    High cost – like we had low cost prior to ACA.

    “Oh, not if YOUR political party does it though.”

    And what is my political party?

  18. It sounds like you know more about this than me. But ….

    What I read was that with non ACA policies, the insurance was only good for 30 days post non-payment or premium but that the ACA extended this to 90 days. That is a significant difference.

    Also, if a provider calls to determine if someone has coverage in the first, second or third months after a premium payment has been missed, what does the insurance company say?

  19. Legacy Flyer,

    This is not a new issue, and it was not caused by the ACA. It happens with fee-for-service type health care plans.

    One of the benefits of an HMO is that they use a capitation process to pay physicians and physician groups. Capitation pays for a set number of people assigned to them, per period of time, whether or not they seek care. This is why HMOs focus on preventative care, and why you must go through your primary care physician to get to a specialist.

    Fee-for-service contracts are different. They bill for each use of service. If the customer does not pay their bill, the contract is void. It falls on the health care provider to collect or eat the bill.

    We live in a brave new world of medical loss ratios. The United States now requires any insurer providing health insurance to a beneficiary receiving government benefits (e.g., Medicare, Medcaid, ACA health plans) to maintain an 85% / 15% medical loss ratio. That means for every dollar received, they must spent $.85 directly on health care benefits for the insured population. The last I checked, 15% is a narrow margin for any business.

    Where this problem hits the hardest is hospitals. The government is demanding to pay less and at the same time wants better quality.

    Kind of sounds like the general American consumer mentality, doesn’t it?

  20. sr,

    I hear what you are saying. And, like you, I have no faith in Congress to fix the problem. Half of them voted for a law before they saw what was in it, and the other half refused to hear what was in it. Still, I have to believe that what we have is better than a single payer system.

    I’ve spent plenty of time in Russia, the UK, and the Far East to know what government run and single payer systems look like. We have a better system, albeit way too expensive.

    I count myself lucky. I grew up in a military family and spent 20 years in the military myself. As a child I had great care, on active duty I had excellent care, and today I enjoy good care from our Nation’s VA health care system. It’s not the best money can buy, but it is the best taxpayers should be expected to fund.

    Frankly, if I thought our government could provide the same level of care for all Americans that it provides our Armed Forces and Veterans, I’d be all for it. Sadly, it can’t.

    So, we’re stuck with the system we have. It’s not perfect, but what is? Go sit in a health clinic in Moscow waiting to see a specialist (and wait, and wait, and wait).

    I’m not defending our health insurers. I know they have issues. I worked for Health Net back in the 1990’s as a director in the IT department. The capitation process is very complex, and there is a limited time within the open enrollment window to refresh provider data. Mistakes happen.

    What concerns me more than the minor hiccups in our health care system is the prevailing American attitude. It’s way too “snarky” for my taste. Americans have stopped helping to find a solution so they can bludgeon the other guy with their righteous point of view. We certainly have a First Amendment right to do so, but what made America great is compromise and a willingness to help not the snark attacks.

    Was not finding a specialist on the first, second or third try really a major failure of the health care system, or was it just a good reason for a rant? In reality, if having a specific health care provider was so important to me, I might have been inclined to ask the provider which health care insurance companies they prefer to work with or I’d buy a PPO or fee-for-service policy that gave me the flexibility.

    We should all stop the ranting and pointing fingers and start talking about what works and what needs to work better. I don’t know about the rest of you, but I work a lot better with positive reinforcement than a verbal whipping. Our health care system is in a transition. It needs guidance more than bashing.

  21. There is another interesting little twist to this as well. Docs that sign up for certain ACA plans can be stiffed out of 2 months bills.

    Here is how it works (as I understand it). Patients are allowed to pay their bills monthly and are given a 3 month grace period for non-payment before their insurance is listed as cancelled. But certain ACA plans only reimburse for bills during the first month of that 3 month period.

    So during the second and third months a patient hasn’t paid, the insurance company will tell a doc that the patient is still covered BUT if the patient doesn’t eventually pay up will deny claims for those months.

    This has been publicized on a number of physician websites like SERMO and, not surprisingly has not been a crowd pleaser. If it was up to me, I would not sign up with an insurance plan that could stiff me like that.

  22. Wasn’t going to comment, but find that I have to. Peter and Cindy, I have no faith in my Congress to fix any of this. I’m not saying to defund the entire ACA, but I really don’t think any of these guys have any idea what’s going, and I don’t trust that they have the ability to fix their toilet with a plumber doing all the work.

    And I totally agree with Joel – he may have sounded snarky, but I’m guessing that what he really was is frustrated. ‘All doctors should be included in all plans’?? You are kidding, right? What utopia is this that we’re talking about (I’m saying this as a doctor and as a hospital consultant).

    David, I have spent hours on the phone with multiple carriers and ehealthinsurance. Aetna alone is known to have multiple plans, and sub-plans, all of which are managed differently. It’s a much bigger issue than just problems with small regional plans.

  23. Do you realize, Peter, that if you agree to be in a plan you can’t turn away patients? Or, you do know that but don’t share that little pearl of information with readers.

    Yeah, I am snarky, with the commenters who are just selling a false promise of hope and faith just filled with slavery and high price cost.

    What criminals can be charged with, eh?!

    Oh, not if YOUR political party does it though.

  24. I deal with plan information day in and day out… including plans on the health exchanges. For the most part, the major health insurance carriers (e.g., Humana, Cigna, UnitedHealth, Kaiser, etc.) have their act together. The plans they offer in the exchanges are managed the same way as those they sell independent of the exchange. It’s the small, regional health plans that seem to have issues managing provider data, in particular if they are trying to expand on the back of a state health exchange.

  25. Joel, you assume a lot of by your snarkyness. I don’t expect docs to be forced to take patients, just that all insurance must cover all docs.

    Agree that congress/senate should be in with us all, as I agree that their kids should be forced to serve in military if they declare war. No I don’t think that will happen – but that’s the system you vote in.

  26. This is nothing new,I saw an eye Doctor last month,was told by my plan he was covered if I saw him at a local Health Clinic,but not at his private office,his staff had no idea.Wound up paying the bill out of pocket,no one could tell me this ahead of time.

  27. Yeah, real nice Peter, what else does everyone HAVE to do to satisfy your party’s zeal to enslave people?! “…ALL doctors should be included in all insurance plans.”

    Yeah, I’ll consider being in every health plan when EVERY single congressman, Senator, and Obama sign a public pledge they will be in the health care process with us all here in the public.

    Gee, think that is going to happen, PETER!?

  28. Totally agree with Peter! “Write your congressman to support changes/improvements – not de-funding.”

  29. “Your OB GYN office should know if they opted in or out of the exchange plans.”

    Sounds about right to me. Even before ACA not all insurance included all doctors – it was/is about protecting turf.

    ACA is a mess right now but ALL doctors should be included in all insurance plans.

    Write your congressman to support changes/improvements – not de-funding.

  30. As someone who has worked the provider management side for many years here in the State of Connecticut, I have to take exception with this. Your OB GYN office should know if they opted in or out of the exchange plans. Communication between management and front office staff is most likely lacking.

  31. These kinds of stories make the “old” system of managed care plans ruling the roost seem downright likable by comparison. At least then you could actually find out who was in network and who wasn’t.

    As for the ACA, well, you can’t fix what you don’t understand.

  32. I think you’re wise to assume you’re doc isn’t part of the network. I doubt that the reimbursement from these exchanges will be very attractive to most practices.

  33. GREAT. We’ve “solved” a fractured and disjointed healthcare system by building an EVEN MORE decentralized and fractured system. Hm.

  34. This is sad but sadly not uncommon in the health care world, ACA or not. And in an exchange world there are going to be narrow-network plans and what many see as not an option (e.g. changing provider) will happen. One of the few ways to control cost.