Almost EVERYONE covered through an employer, union, individual or Medicare Advantage Plan has a network of providers. Network providers have contracted with your insurer to abide by the insurer’s rules and to accept the insurer’s negotiated rates.
If avoiding unexpected medical bills is important to you, then you must understand your network. When verifying that a provider is in-network, use the Provider Search tool on your health insurance portal. Even if you find the provider, call the office to verify status because directories can be out of date.
Never ask “Do you accept my Plan?” The correct verbiage is “Are you in-network with __________” and specify your insurer AND the product. And don’t assume that all physicians in a given practice or physical location have the same relationship to an insurer.
There are certain categories of providers like ambulance and air ambulance that often don’t maintain in-network relationships. The best way to handle those situations is to ask the insurer to assume responsibility for negotiating with the provider, if at all possible. Surprise medical bill legislation takes effect in January 2022 which will provide more consumer protection in emergency situations.
There are other categories of providers affiliated with hospitals who often choose to be out-of-network such as emergency room physicians, anesthesiologists, and neonatologists. If you receive large, unexpected bills from these providers while you were receiving care at an in-network hospital, you should ask your insurer to negotiate directly with those providers. If the insurer will not, review your appeal process and consider filing an appeal with your insurer. Again, federal legislation taking effect in January 2022 will help protect consumers in these situations.
At times, in-network provider offices can engage in unfortunate billing practices, but because the providers have a contract with your Plan, you have more protection should that happen.