Is your doctor accepting your health insurance plan? It’s hard to tell, even for your doctor’s office.
When you call and ask, you probably tell them you have a PPO from one of the top three insurers. Let’s use Anthem Blue Cross as an example. If you have a doctor who takes Anthem Blue Cross PPO coverage, you still might get billed for an out of network service. That’s because there are nine different PPO provider networks that doctors can be in, or out of. There is one for large group plans, another for small group plans, one for older grandfathered plans, one for grandfathered individual plans, one for new plans bought through Covered California, and yet another for new plans bought outside of the exchange, such as directly from the insurer.
When you visit your doctor the next time, his staff will ask if you have new insurance so they can call the number on the back of your card to verify they are part of your provider network and that your insurance is valid. Until they call, even they are not sure. On the newest plan I.D. cards, the network is listed at the bottom of the card. Any new 2014 plan is probably part of the Pathway network. If you enrolled through Covered California (known as “The Exchange”), your card will be labeled Pathway X.
The only difference is how much the doctor is going to get paid. For some doctors, especially a large practice with high overhead, it may not have been feasible for their business to accept every PPO from a given insurer, so they may take some PPO plans, but not all. For others, it makes good sense to be one of the practices accepting new patients and new health plans.
Unfortunately, there are currently no physicians in the Coachella Valley accepting the Anthem Blue Cross HMO sold through Covered California. If you are enrolled in one of these plans, please call your agent or Anthem Blue Cross to be changed to another plan, preferably a PPO.
And that is really what the current situation comes down to. Some doctors decided to help new patients who have not had coverage in years and accepted these new plans. Others made decisions based solely on their financial business model. One doctor went so far as to tell me that the reimbursements to him under some new plans were, in his words, “insulting.”
If the doctors, facilities and providers in our society can’t see that helping the newly insured get badly needed health care is good business and good for the community, then who is really being insulted? Maybe it’s the rest of us who believe that quality health care for all should come before profit margins.
No matter what your health plan, check your provider network before you visit the doctor.
Randy Foulds is a Certified California Exchange Health Insurance Agent (license #0G69218) with Feldmann Insurance and can be reached at (760) 346.6565.