Dealing With Health Insurance Companies: Doctor Networks
Megan is from the Stride customer support team and is an all around health insurance pro. A licensed agent (maybe the 007 kind? we're not sure yet), Megan can hassle insurance companies like it's nobody's business. Send questions about your plan or application her way.
What is a doctor network?
Each insurance company "contracts" with hospitals, doctors, nurses and other medical providers who agree to charge a discounted price for their services. This group of providers is called a "network." Most plans only cover you if you get services from a medical provider in your network, although there are some exceptions. We’ll get into that later on.
What kinds of networks are there?
click the name to learn the nitty-gritty.
- HMOs only cover you if you stay in-network and require referrals to see specialists.
- PPOs often have more expensive premiums (monthly payments), but offer partial coverage if you go out-of-network and don't require referrals to see specialist.
- EPOs also only cover you if you stay in network, but you can see specialists without referrals. Think of them as in-between an HMO and a PPO.
How do I know if a doctor I’m seeing is in my network?
Unfortunately, doctor networks aren’t always as straightforward as they should be (welcome to the world of health insurance!). If it gives you a headache, you’re not alone. That’s why we’ve put together some tips to make the process easier:
- Know your plan. Get familiar with your plan’s name, metal tier, and network type. This should all be available on your insurance card.
- Ask your doctor. Call the doctor you plan on visiting and ask if he/she is covered by your plan. Make sure to give them those specific plan details so they can get you accurate information. Important: Tell your doctor whether your plan is on-exchange (you got a subsidy or bought from government site like Covered California) or off-exchange. Sometimes doctors won’t accept your coverage if it’s on-exchange.
- Pro Tip: Doctors often practice at different facilities and all locations won’t be covered by your plan, so make sure your visit is at the right office. If you’re misbilled for an out-of-network visit, double check...there’s a chance your doctor just put the wrong location on the paperwork. Good times, right?
- Do online research. Many health insurance companies have a “find your doctor” feature that lists which doctors are covered by which plans. Pro tip: Sometimes insurance companies will refer to their doctors as “providers.” Here are the doctor search pages for a few common companies:
- Google your hospital or doctor’s office. Can’t get info from anyone else? Explore the actual health care facility's website. They often have lists of the health insurance companies and plans they accept.
Note: double-checking with your doctor via phone is always your safest bet. Health insurance companies tend to be slow at updating their websites :/
What happens if I see a doctor that’s not in my network?
This totally depends on which plan you have. If you have a less expensive monthly premium, you’ll most likely have to pay full price for your doctor visit. Sometimes, more expensive gold and platinum plans will partly cover out-of network care; there’s a chance, though, that what you pay for these visits will apply to a separatedeductible and won’t count toward the out-of-pocket cap on how much you pay in a year for medical costs.
Our best advice? Try your best to stick in-network, and if you’d like to know how your plan covers out-of-network costs, just give us a buzz...we’ll look into it.
- Pro Tip 1: If you end up being charged for an out-of-network visit, you may be able to appeal...especially if you can prove the visit was medically necessary and you couldn’t get the care you needed in-network. Check out our quick guide to the perfect appeal here.
- Pro Tip 2: If your doctor leaves your network, he/she should notify you and you may be required to find a new one. However, some companies like Blue Cross Blue Shield will let you continue to see the doctor in special circumstances (you’re in the 2nd or 3rd trimester of a pregnancy, you’re being treated for a terminal illness, etc.).
Still feel helpless? Don't sweat it. Email us at firstname.lastname@example.org or give us a call: 415-886-1966. We've got your back!