Provider Networks

This week I would like to highlight why considering provider networks is important.

Many insurance companies work with specific doctors and hospitals, and they are referred to as ‘in-network’. This usually means that by using an in-network doctor you would save money and that it would cost you more to use an ‘out-of-network’ doctor.

This means that it is very important to do your homework ahead of time. Select your providers ahead of time. Knowing who your doctor is, is easy. But if you’re very sick, or you have an emergency, do you know who’s in-network and where you should go?

One of the things I teach all my policyholders to do is to look up the closest urgent care center and then look up the nearest ER that is in-network for you. The nearest one to you may not be one that is in-network for you, and this is important to know. You want to write that down and take note of it. In case there is an emergency, you want to get to the place as soon as possible. When an emergency arrives, it is certainly not going to be at the top of your mind to figure out “where do I go, who’s my provider?”. You just want to be cared for or have your loved one cared for. But, when the bills come later, you realize that you should have figured out who was in-network and who did not network.

Looking it up ahead of time is ideal. But there is something else you need to do as well. You need to check with these network providers to make sure they always bill in-network. What I mean by that is there are actually some standalone urgent care centers that do bill as urgent care centers but only for certain periods of the day. I came across a client that went to an urgent care center that was in-network, but it was after 8 pm. They billed as an ER, and his bill for that coverage was much different. So, you have to be your own advocate. I know I say this a lot. But you can’t just pay the premium. Everyone grips about how high premiums are, but nobody wants to take the time to figure out how to save themselves some money. It does require some effort on your part and is worth it.

The other thing you need to do is always make sure you have checked if the hospital and doctors are in-network if you have a planned procedure. I had it happen to a client recently. They had a baby, and the OB-GYN and hospital were in-network. Apparently, the pediatrician on call that weekend was not in-network, and so they were stuck with a $7,000 bill because the hospital utilizes out-of-network providers. This is something you can ask the hospital ahead of time if it is for something planned. It is important to find out if they use any out-of-network providers. If they don’t know, then get a list of doctors who could potentially be on call at that hospital. I mean, hopefully, that list isn’t too big – it depends where you go. But there may be a way to request an in-network provider. If it happens that you do get stuck with an out-of-network provider, you call them and let them know that you will be a cash patient, and find out what the cash price will be for that procedure. Their cash price is going to be a fraction of the cost. Bear in mind that they may not want to give it to you, and they’re not going to give it to you without you asking. But if they expect to get paid, then they’re going to have to give you a cash price. You will have to be persistent with them. And tell them that it is your fault that they are not in-network, you had no control over who the hospital had on call. There is also the option to tell them that if they don’t want to work with you on this payment, then you will pay $10 a month till it’s done. Which they don’t want to do – I can promise that as I worked in medical offices. So what you do is you offer them a fair amount (which is about 30% of the total bill), offer it in either in full cash or credit card in full right now, if they will accept that as payment in full. And a lot of times you can do that.

It is understandable that things happen and you can not get all this information ahead of time. But sometimes you can, and by doing that, there’s a good chance you can help minimize your out-of-pocket expenses.

Remember: ask questions, ask questions, ask questions.

Be your own advocate.

Don’t pay a medical bill for an emergency for an out-of-network provider without negotiating a cash price.

And know that it can take time. It recently took me 15 months to resolve a lab bill. I ended up paying nothing because I knew it was covered by insurance, and that they kept coding it incorrectly. I had to get the doctor’s office involved as well as the lab till it finally was resolved and we paid zero out of pocket. It was time and effort – but it was worth it.

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