Using a Primary Care Physician Not Covered By Your Insurance
December 11, 2019 2:40 PM Subscribe
What are some unexpected pitfalls if my primary care doc doesn't participate in my insurance plan?
FWIW:
*I'm considering MVP plans on the New York exchange (they don't pay out-of-network).
*I like my PCP, but she doesn't accept any plans that work for me. I don't see her often, and her charges are reasonable.
*Most of my expenses are with specialists, labs, and prescriptions. The plans I'm looking at don't require referrals.
*I'm guessing bloodwork and other tests ordered by her would not be covered (even if they're completed by labs that are participants).
FWIW:
*I'm considering MVP plans on the New York exchange (they don't pay out-of-network).
*I like my PCP, but she doesn't accept any plans that work for me. I don't see her often, and her charges are reasonable.
*Most of my expenses are with specialists, labs, and prescriptions. The plans I'm looking at don't require referrals.
*I'm guessing bloodwork and other tests ordered by her would not be covered (even if they're completed by labs that are participants).
As long as you don't need referrals this isn't a problem I think. I ran afoul of this recently where everything needed a referral and they wouldn't take from my PCP because out-of-network. That gets very expensive in a hurry so worth avoiding.
posted by leslies at 3:31 PM on December 11, 2019 [1 favorite]
posted by leslies at 3:31 PM on December 11, 2019 [1 favorite]
Is your PCP solo or part of a group practice? If the latter, the practice manager rather than the doctor would be the one to speak to. I'm in an academic practice and have no control over the financial side other than OK'ing someone seeing me if they don't have their co-pay on them (but they get a bill in the mail, so it's not actually a discount/waiver).
Labs are usually billed by the lab location, not the ordering physician. So you could still have stuff done at an in-network facility. Unfortunately it's going to be really hard -- nearly impossible -- for your PCP to know how much testing or drugs will cost; every system I've ever worked in sequesters that information in a hidden ChargeMaster with monopoly money pricing. (I once had a patient's family accuse me of purposely withholding pricing information, so I had them call their insurance company on speakerphone and after we waited on hold forever, the insurance person confirmed to us that there was no way to know how much the medication was going to cost until AFTER it was dispensed. It's like going to a restaurant where the menu doesn't have any prices and you get the bill only after you've consumed the food.)
The only point of caution I'd have is that evidently the Marketplace plans only cover preventative services if ordered by an in-network doctor. Here's a list of services recommended by the US Preventative Services Task Force.
posted by basalganglia at 3:39 PM on December 11, 2019 [1 favorite]
Labs are usually billed by the lab location, not the ordering physician. So you could still have stuff done at an in-network facility. Unfortunately it's going to be really hard -- nearly impossible -- for your PCP to know how much testing or drugs will cost; every system I've ever worked in sequesters that information in a hidden ChargeMaster with monopoly money pricing. (I once had a patient's family accuse me of purposely withholding pricing information, so I had them call their insurance company on speakerphone and after we waited on hold forever, the insurance person confirmed to us that there was no way to know how much the medication was going to cost until AFTER it was dispensed. It's like going to a restaurant where the menu doesn't have any prices and you get the bill only after you've consumed the food.)
The only point of caution I'd have is that evidently the Marketplace plans only cover preventative services if ordered by an in-network doctor. Here's a list of services recommended by the US Preventative Services Task Force.
posted by basalganglia at 3:39 PM on December 11, 2019 [1 favorite]
Response by poster: Odd, I’ve been paying (and paying) for statins all these years (I am high risk) and no one ever suggested they should be free!
posted by Quisp Lover at 4:22 PM on December 11, 2019
posted by Quisp Lover at 4:22 PM on December 11, 2019
I don't see her often, and her charges are reasonable.
It is worth seeing if you're seeing her charges or the charges she has that are allowed by your current insurance. The way my plan works is that my doc costs some amount (let's say $150) and my insurance only allows a doc visit to cost so much (let's say $100) and then it covers a certain amount of that (let's say 50%) so in the end, I pay $50. Without insurance I wouldn't pay $100, I'd pay $150.
posted by jessamyn at 4:36 PM on December 11, 2019
It is worth seeing if you're seeing her charges or the charges she has that are allowed by your current insurance. The way my plan works is that my doc costs some amount (let's say $150) and my insurance only allows a doc visit to cost so much (let's say $100) and then it covers a certain amount of that (let's say 50%) so in the end, I pay $50. Without insurance I wouldn't pay $100, I'd pay $150.
posted by jessamyn at 4:36 PM on December 11, 2019
There's always the risk that you'd lose continuity of care when your specialists and PCP aren't on the same medical records network. For example, an ER or urgent care visit might not automatically show up for her.
Also, if she has specialists she likes to work with, they might not be in your network either. While you don't need a referral, you would be losing out on any relationships she has (awhile ago my doc got me in to see the endocrinologist that week instead of the 2+ months it would otherwise take).
posted by cabingirl at 4:49 PM on December 11, 2019 [1 favorite]
Also, if she has specialists she likes to work with, they might not be in your network either. While you don't need a referral, you would be losing out on any relationships she has (awhile ago my doc got me in to see the endocrinologist that week instead of the 2+ months it would otherwise take).
posted by cabingirl at 4:49 PM on December 11, 2019 [1 favorite]
I do this. I'm in California, but I think the principle is the same. I have a medical group that doesn't take my insurance, and hasn't for years. I pay out of pocket for appointments and procedures. They have a cash / out of pocket discount, and are super lenient about how they code visits and often don't charge me for stuff because they know I'm not insured. I did have labs last time I went, and they looked up the price before I agreed to have them done. I did get billed directly by LabCorp, and the price was exactly as quoted. If you are used to looking at treatment costs as itemized for insurance, you are in for a pleasant surprise at how cheap the cash prices are for everything.
Anecdata: I broke my elbow a few years ago. I was newly back in the country and uninsured. I went to my walk-in clinic, and the doctor there found a place that does xrays for $100. I went and got xrays, and that clinic put my arm in a splint, changed it every two weeks, and gave me a list of PT exercises to do. Total out of pocket cost was $140. So, yeah, barring serious emergencies I would say that out of pocket is more doable than a lot of Americans realize.
posted by ananci at 5:15 PM on December 11, 2019 [1 favorite]
Anecdata: I broke my elbow a few years ago. I was newly back in the country and uninsured. I went to my walk-in clinic, and the doctor there found a place that does xrays for $100. I went and got xrays, and that clinic put my arm in a splint, changed it every two weeks, and gave me a list of PT exercises to do. Total out of pocket cost was $140. So, yeah, barring serious emergencies I would say that out of pocket is more doable than a lot of Americans realize.
posted by ananci at 5:15 PM on December 11, 2019 [1 favorite]
Doctors not taking your insurance is not the same thing as your insurance not covering a specific doctor. What it means when a doctor takes you're insurance is that the office is familiar with how your coverage works/understands how much your insurance will and won't cover (fee? deductible? co-insurance? %?), and they themselves will submit a claim. in that meantime they are taking a deficit in pay, while they wait for the insurance to send them the money.
When an office does not take your insurance, they are saying that they don't know how much you are covered, and will not be sending a claim for reimbursement. therefore you are responsible for paying the amount in full. Depending on your insurance, this does not prohibit yourself from filing a claim for reimbursement.
What you need to do is either read over your insurance or call them and figure out if they cover "out-of-network" doctors. With my insurance, it does. It covers less, and has a higher deductible, but it still covers medical treatment. If this is the case, you pay out of pocket at your physicians office, and every time submit a claim with your insurance company. Once the amount you pay is higher than the deductible, the insurance company will reimburse you for each visit you make a claim towards. For me, for example, after i met the deductible, they would reimburse me %50 of the cost of the visit. And then after you pay the out-of-pocket-maximum, they reimburse it %100.
posted by FirstMateKate at 2:57 PM on December 12, 2019 [1 favorite]
When an office does not take your insurance, they are saying that they don't know how much you are covered, and will not be sending a claim for reimbursement. therefore you are responsible for paying the amount in full. Depending on your insurance, this does not prohibit yourself from filing a claim for reimbursement.
What you need to do is either read over your insurance or call them and figure out if they cover "out-of-network" doctors. With my insurance, it does. It covers less, and has a higher deductible, but it still covers medical treatment. If this is the case, you pay out of pocket at your physicians office, and every time submit a claim with your insurance company. Once the amount you pay is higher than the deductible, the insurance company will reimburse you for each visit you make a claim towards. For me, for example, after i met the deductible, they would reimburse me %50 of the cost of the visit. And then after you pay the out-of-pocket-maximum, they reimburse it %100.
posted by FirstMateKate at 2:57 PM on December 12, 2019 [1 favorite]
Best answer: Sounds like you’ve established that your current insurance doesn’t cover OON doctors.
I would just ask your doctor’s business manager what the cash pay cost of a 99213 or 99214 office visit is (those are the codes for the 2 most common primary care visit types.) and decide if that’s affordable to you. You will need to be aware that everything she does (EKG, flu shot, etc) will be an additional charge. But if you’re someone who goes in a couple of times a year for a follow up and you’re ok with paying a couple of hundred dollars to continue working with someone you like it should be ok. Labs and imaging can still be done at in-network sites with orders from your doctor, although you may have to do some due diligence in figuring this out for yourself and reminding your doctor if you need to go somewhere other than her default site. (We have a Labcorp phlebotomist on-site in our office and so my few patients who have to go to Quest locations have reminders all over their chart that they shouldn’t get labs in the office. ).
I’m a primary care doctor with a couple of patients like this and it works out ok. I do like it when they remind me that I’m OON bc we can talk about ways to reduce costs (like getting the flu vaccine at a pharmacy) or at least talk about anticipated costs.
My husband’s PCP is currently OON on our insurance and we haven’t bothered to change because I expect to only have our current insurance for 2-3 years before switching to something that will be in network again, and he only goes to the doctor twice a year or so.
posted by The Elusive Architeuthis at 10:46 PM on December 12, 2019
I would just ask your doctor’s business manager what the cash pay cost of a 99213 or 99214 office visit is (those are the codes for the 2 most common primary care visit types.) and decide if that’s affordable to you. You will need to be aware that everything she does (EKG, flu shot, etc) will be an additional charge. But if you’re someone who goes in a couple of times a year for a follow up and you’re ok with paying a couple of hundred dollars to continue working with someone you like it should be ok. Labs and imaging can still be done at in-network sites with orders from your doctor, although you may have to do some due diligence in figuring this out for yourself and reminding your doctor if you need to go somewhere other than her default site. (We have a Labcorp phlebotomist on-site in our office and so my few patients who have to go to Quest locations have reminders all over their chart that they shouldn’t get labs in the office. ).
I’m a primary care doctor with a couple of patients like this and it works out ok. I do like it when they remind me that I’m OON bc we can talk about ways to reduce costs (like getting the flu vaccine at a pharmacy) or at least talk about anticipated costs.
My husband’s PCP is currently OON on our insurance and we haven’t bothered to change because I expect to only have our current insurance for 2-3 years before switching to something that will be in network again, and he only goes to the doctor twice a year or so.
posted by The Elusive Architeuthis at 10:46 PM on December 12, 2019
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It would also be a good idea to inform your PCP regularly that you are not covered by insurance. Many doctors have a habit of recommending overly broad tests/drugs/etc in order to maximize the benefit from insurance. Many doctors will similarly change their approach if they know you are paying out-of-pocket.
posted by saeculorum at 2:43 PM on December 11, 2019 [1 favorite]