Doctor/Insurance question

[Beth76]

To determine if a certain doctor is covered under my plan who should I call? The doctor or the insurance company or both (just to make sure)?

 

[Cindy's Mom]

I would call the insurance company first, then if the Dr. is on the plan, call the Dr. to see if they are accepting new patients.

 

[Bob Slydell]

The insurance company first and if they happen to say that the doctor is not included in their plan, call the doctor to double-check (sometimes insurance company's records -- especially on-line -- aren't always completely up-to-date).

You shouldn't have to call both. If your carrier says the doctor's on the plan, you're fine.

 

[Beth76]

thanks. This is so not my thing. What would I do without you guys!

 

[puffkin]

Our health insurance has a website that lists all participating doctors. You can search by numerous criteria, such as Dr. name or specialty.

I would then call the dr. office to make sure they are still participating and also to check if they are accepting new patients (though the website lists that too for our insurance).

 

[figment52]

Our health insurance has a website that lists all participating doctors. You can search by numerous criteria, such as Dr. name or specialty.

I would then call the dr. office to make sure they are still participating and also to check if they are accepting new patients (though the website lists that too for our insurance).

The Dr. can opt out of being listed on the Web site. I couldn't believe it either but my Dr. wasn't listed but his office told me he took the inusrance so I made an appointment. I had an opportunity to go to the Insurance office and meet some people (I am plan administrator for the company I work for) and they pulled him up and showed me he had been active with them for years but was on the non-publish list.

I haven't trusted an omission on the Web site since, I always call.

 

[lemondog]

Definitely CALL the insurance company. When my DD needed dental work done my family dentist recommended a pediatric dentist to treat her. I called that dentist and asked if they accepted MetLife dental. I was told, "yes, we file with MetLife." Now what would you take that mean???

So anyway we show up for the appt. and the woman (same woman who I talked to on the phone) says, "well, we are not contracted with them so you'll have to pay a higher rate." I told her that I called and she specifically told me they took MetLife. To which she replied "no, I told you we file them. That doesn't mean we are contracted with them." She could have made that clear when I called!!!

So I ended up paying a lot more for the dental work because I didn't cover ALL my bases and check directly with the insurance company.

 

[j's m]

I would call the insurance company, verify with the doctor's office, and then call the insurance company again to talk to a different person.

Just because the insurance company verbally tells you, the doctor is participating, doesn't mean it's so. If you really want to be covered, try to get it in writing.

I speak from personal experience, we needed to find a new pediatric urologist and NJ BCBS gave us a huge runaround as far as helping us find participating doctors. It also turned out that a doctor from CHOP in Philadelphia was covered in PA but not in NJ where we live. Confusing. We got differing info from both the doctors office and the insurance.

But the best one was the book of participating doctors. One doctor that we know personally was in JAIL for medicaid fraud was still listed as participating!

 

[rascalmom]

I would call both. I recently had surgery on my leg & the surgeon that I wanted was not listed by the ins. co. The doctors office told me they would discount my fee to what "plan" doctors accept - they mentioned this, I didn't ask for any special consideration.

So, they processed the claim & got their usual reimbursment from the ins. co., but I only had to pay the co-pay equivalent to what I would have paid with a participating doctor.

 

[CJMickeyMouse]

To be safe, call both. We have dealt with many disappointed customers who were told by their insurance company that our pharmacy would accept their policy, when in reality we had no contract with them and never did.

I think it's just another ploy on the insurance company's part to strong arm people into accepting their policies. They sell to the consumer saying "everyone" will accept it.... then hope when the consumer walks into the office/pharmacy/etc with that card that they will feel pressured to accept it (meaning they might sign a contract they would normally reject).

IMO, insurance companies are vicious.

 

[bettyann29]

Personally I wouldnt call the drs office to verify that because the insurance co is the one in the end thats gonna pay the bill.. Alot of drs are on so many plans that they dont always know what they're on.. example.. Blue Cross.. there are different plans.. Hmo, PPO, POS, etc.. they may be on one but maybe not all.. Id call the insurance company and get the name of the person who told you along with the date you talked to them.. that way if there is a problem you have a backup.. I would call the dr to make sure they are accepting though.. sometimes they close practice to new patients..

 

[CJMickeyMouse]

Personally I wouldnt call the drs office to verify that because the insurance co is the one in the end thats gonna pay the bill.

You are correct about the different plans... it's all very confusing, but to assume the insurance company is going to pay because they told you that a certain Dr/pharmacy/etc. accepts their plan is really treading on thin ice. They cannot pay if the Dr/pharmacy/etc. cannot submit claims to them, which they cannot do if they do not have a signed contract. So you may end up holding the bill if your provider provides service without checking into your insurance first. (Which they definitely should do, but it does not always happen that way). A less costly issue is the waste of time and delay of treatment if you set up an appointment with a busy physician because your insurance co. told you they accept it.... only to find out when you arrive that they do not in fact accept your insurance.

It is really getting to be a near impossible situation. Don't even get me started on Medicare Part D. We have people in our area randomly assigned to insurance that is only accepted by providers that are two hours away.

 

[malibuconlee]

You can usually print out a list from your ins company's website. Do print it out, because the first one you call off the list might not be accepting new patients. I've had that happen to me before. We actually were routed to three different doctors in the same practice before we found the "new guy" that was accepting new patients. Turned out fine. Was kind of wierd having a doctor only 6 months older than me. He's younger than DH and we're only 30 and 32.

 

[HoneyPooh]

Call your insurance carrier and get a list of participating doctors. After that, call the doctors office and check. I get about 10 calls a day from people who tell me that the carrier said they can come to us but we actualy don't participate and never did. They can come, but they will pay far more than they should have to because their coverage will only pay us as a non-par provider. Don't ever take the insurance company as the last word. I ask patients what insurance they have when they call to make their appointments and (because I do in fact know every insurance we accept, it's what I'm paid for) I let them know if we do not accept their plan/carrier. Heads off a lot of problems. Customer service reps at insurance carriers are not perfect and neither are doctors office personnel, but between calling both you should be safe