Theathens Directory

If you are currently covered by health insurance, or are investigating new health insurance options available to you, it is always vital to know whether your physician and hospital will accept the coverage you have or will be purchasing in the future. This is important for a number of reasons, primarily to ensure that when medical services are rendered, you will not receive reduced coverage by your health insurer, or even be required to pay the full out-of-pocket cost to a non-network provider. If you have a PPO plan (Preferred Provider Organization) type policy, but it does not cover certain types of medical procedures, or perhaps you were ridered (i.e., the plan declined pre-existing conditions coverage for a period of time), you may still at the very least qualify for network repricing, or lowering of the charges to reduced rates, if your provider does in fact accept that particular plan’s PPO network.

There is no substitute for doing a little research by reading your policy carefully and asking a good health insurance agent or broker which doctors or physician networks will accept the plan. While it is permissible to call your doctor’s office to find out if they will accept a certain plan, this is not always reliable as oftentimes the doctor’s office may not be familiar with every carriers’ plan offerings. For example, if you were to call in to your physician’s office and mention to the billing staff that you are going to be changing to Aetna health insurance, they may readily state that they are happy to accept Aetna’s plans, but in reality they may accept MOST but not necessary ALL of Aetna’s plan offerings. And so one might be unpleasantly surprised after purchasing the coverage that it is not going to be quite so acceptable after all.

A good way to ensure that this does NOT happen to you is to find out exactly which type of coverage you are considering, and more specifically, the plan’s exact name. Then you may refer to the carrier’s website where you can check to see if your physician is in the provider directory for that particular plan. An online provider directory is usually superior to a printed booklet directory in that the information is generally current and the provider list is updated frequently to reflect the providers recently joining the network, as well as to exclude providers who have recently left the network.

In some cases, especially when you have group health insurance through an employer, the carrier covering you may contract with a large independent national PPO network to provide its repricing and negotiation services. Usually this network will be shown somewhere on your health insurance ID card. In that case you may need to look up providers at that organization’s website. An example of a large national network that numerous reputable insurance companies often contract with is Multiplan. The provider directory in this instance could be found at Multiplan.com.

A question you might ask yourself in the event that you have found a plan that you would like to purchase but your doctor does not accept it is: are you willing to change providers? If you are not necessarily joined at the hip with your primary care physician or specialist, and are willing to change to other suitable providers of varying specialties that are in the plan’s network, then you may feel that it could still be a wise decision to purchase the new coverage. Or you may decide that even if the provider does not take the insurance, you will just pay that provider directly without regard to the insurance, and simply utilize your coverage for the event that a more catastrophic medical situation arises.

One other option is to purchase supplemental indemnity coverage, which can reimburse you directly a stated benefit amount for many types of medical procedures, including office visits. A big advantage to this approach is that the plan will usually reimburse you for ANY licensed physician that you choose to visit without limiting you to a certain list of doctors. This supplemental coverage may also help cover any deductibles or coinsurance that your primary health insurance plan may require you to pay.

Also if you are considering applying for medically underwritten insurance, be aware there is a chance you might be declined due to preexisting conditions. In that event you may want to explore certain guaranteed acceptance health insurance options. Again the suggestions of a good health insurance agent or broker, in addition to your own research and the advice of other friends and family members who have experience in this area may be helpful.

By: Brandon Sears

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