Doctor Networks: 3 Tips to Finding An In-network Provider
As you evaluate insurance plans in your zip code and try to choose your insurance plan, you probably keep seeing HMO, PPO, and EPO, as well as the phrase “doctor network” pop up all over the place. If you are wondering what that all means and how it will play a role in finding a doctor down the road, you aren’t alone. But don’t worry, Stride has you covered! Read on to learn more about doctor networks and how you can go about finding an in-network provider.
What Is a Doctor Network?
A doctor network, oftentimes referred to as a provider network, is a list of hospitals, doctors, nurses, and other healthcare providers that a specific plan has contracted with to provide care at a discounted price. Providers on this list are considered “in-network,” while providers not contracted with a plan are considered “out-of-network.” Different types of plan networks cover services from out-of-network providers differently. Some might offer partial coverage, while others might not. We’ll get into that next.
Types of Plan Networks Explained
There are four primary types of plan networks that you will encounter as you shop around for a plan. As you learn more about these, be sure to think about which would best suit your needs!
HMOs only cover you if you see an in-network provider and require referrals to see specialists.
PPOs often have more expensive monthly payments (AKA premiums), but offer partial coverage if you go out-of-network, and they don't require referrals to see specialists.
EPOs also only cover you if you stay in-network, but you can see specialists without referrals. Think of them as hybrid of an HMO and a PPO.
POSs offer partial coverage if you go out-of-network, but require referrals to see specialists. POSs are also a hybrid of an HMO and PPO.
Looking for a more in-depth explanation so you can better evaluate these plan network types? Read more and take our short quiz to identify which type is best for you here.
How Do I Know If I Have An In-network Provider? 3 Ways to Check
With all of this talk about staying in-network, you are probably wondering how to actually check if a provider is in-network with a health insurance plan. While doctor networks aren’t always as straightforward as we’d like them to be, we’ve outlined three simple options you can use to make sure you see an in-network provider that you love!
Pro Tip: Before you start checking to see if your provider is in-network, make sure you are familiar with the plan name, metal tier, and network type. This should all be available on your insurance card or Stride’s website if you’re still evaluating plans.
Call the provider’s office. Not every doctor at a medical practice will accept the same insurance, so make sure you have the specific name of your health plan and the specific name of your doctor when you call. The best way to ask is by saying “I would like to check if Dr. John Doe is in-network with Blue Shield Gold 80 PPO.” Further, be sure to tell your doctor’s office whether or not you have a marketplace plan, (ie: you qualify for a government subsidy or purchased from healthcare.gov) because providers sometimes won’t accept marketplace plans. By getting specific, you can help ensure that you are getting the most accurate information (and don’t end up with a surprise bill down the road!).
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.
If you can’t get an answer by calling the provider’s office, don’t fret…
Call the insurance carrier. Insurance carriers can check if a specific provider is in-network by looking up their specific tax ID number. You can get this by first calling your provider’s office and asking for your specific doctor’s tax ID number. Once you have this on hand, give the insurance carrier a call at their general number (you can find this with a quick Google search of “[insurance carrier] customer service phone number”). Let them know you want to check if a provider is in-network, and give them both the specific plan name you are referencing and tax ID number. They should be able to confirm whether or not the provider is in-network.
That still didn’t work?
Do some online digging. Most health insurance carriers have a “find your doctor” feature that lists which doctors are covered by which plans. Here are the doctor search pages for a few common companies:
You can search by name to see if they are in-network provider. On the other hand, if you are looking for a new provider, use the online directory to search for a doctor in your area that is in-network.
What Happens If I See An Out-of-network Provider?
You’ve probably guessed it already…this totally depends on which type of plan network you have! PPOs and POSs will likely cover a portion of your visit; the exact percentage will vary since out-of-network benefits are different across plans. In contrast, HMOs and EPOs will not help cover your out-of-network visit. While we recommend seeing an in-network provider whenever possible, we understand accidents happen and medical incidents arise. If you saw an out-of-network provider and want to try to avoid those costs, we have a few tips for you.
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.
Pro tip 2: If your doctor leaves your network, he/she should notify you and you may be required to find a new doctor. 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).
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