What do you mean my doctor is not accepted in your network? I asked if they accept my insurance before I went!

I read a post in the NAHU agents blog today that said “..Always add the caveat that the client needs to confirm with the doctor/hospital that their insurance is in fact accepted, ideally in an e-mail.”  (NAHU (nahu.org) is the National Association of Health Underwriters and is the professional organization for people like me who work in health insurance and employee benefits.)

OK back to the subject. Yes it is important to ask if your physician “accepts” your  insurance but it is even more important to ask  “Are you a contracted provider?”

The majority of medical providers will say yes if you ask if they accept your insurance. (unless it it Medicare and they may say they do not accept Medicare patients.) This does not mean they will be “in network” and thus be subject to the contracts that limit what the physician may charge you.

Here are some terms you need be aware of:

Contracted Provider: A medical provider who has agreed to a contract to provide services for a medical plan that you are a currently covered by.

Balance billing: If you use a “non contracted” provider they may accept what your insurance pays and then bill you for the “balance” which is whatever they feel remains of the bill.

Out of Network: This refers to a provider that is not contracted with the network of medical providers you have an agreement with. They may tell you they “accept” your insurance but they do not have to accept any limits from your insurance nor PPO network.

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For more information, contact Bill Weaver, Focus Benefits Group, 602-381-9900.

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