Insurance and the answer I seek
November 24, 2020 1:04 PM Subscribe
I am trying to select government insurance. I've just about given up on it. I have been sent to my doctors' billing dept (in her clinic) and then they send me back to the central billing dept (for the whole city) and then they send me back to my dr's office billing dept. One keeps sending me back to the other. This was the suggestion of the HealthCare.gov people.
I just need to (try to) get insurance for 2 docs, my GP and another specialist. Last year I ended up paying full price, (which is about $350 for 15 minutes with my GP) even though HealthCare.gov's specific insurance I viewed indicated my doc took that particular brand. (Health.gov is telling a tiny white fib. my GP didn't accept it.)
How do I get these people to talk to me? Everyone wants to pass the buck.
I just need to (try to) get insurance for 2 docs, my GP and another specialist. Last year I ended up paying full price, (which is about $350 for 15 minutes with my GP) even though HealthCare.gov's specific insurance I viewed indicated my doc took that particular brand. (Health.gov is telling a tiny white fib. my GP didn't accept it.)
How do I get these people to talk to me? Everyone wants to pass the buck.
I literally just had to call each of my doctor's office and ask if they accepted specific plans. They couldn't just give me a list of ACA plans they took, I had to ask them about each one specifically. What was listed on Healthcare.gov was incorrect, and often what was on a doctors own website was incorrect because it changes so often. So... I narrowed it down to about three specific plans I liked/could afford. Then I called each doc (GP, gyn, endo, derm) to see if they accepted those plans. It took me multiple calls and ultimately, I never found one plan that covered all of them. I had to switch endos for a while.
posted by kimdog at 1:15 PM on November 24, 2020 [1 favorite]
posted by kimdog at 1:15 PM on November 24, 2020 [1 favorite]
A little more detail would be helpful: what does your doctor's office say when they send you to central billing and vice versa? If it's "we don't know" than that is incorrect; someone in that office knows whether they take a particular plan or not. But if you're asking them "which insurance should I choose?" that is out of scope for their jobs, I think. If you ask them about specific plans (I agree *plans* not companies), yes or no, that should be fairly easy to do. (BTW this is not a healthcare.gov thing, I had the same mismatch happen with my private insurance.)
posted by emkelley at 1:17 PM on November 24, 2020
posted by emkelley at 1:17 PM on November 24, 2020
Response by poster: kimdog--My issue, though: I can't get a real person at my docs office to talk to me that doesn't want to switch me somewhere else.
emkelly--I am talking to my doc's billing office asking if they take xyz insurance. Then I get, "You'll have to talk to billing. Hold please!" Rinse and repeat. I would agree it is not their job to pick an insurance for me.
posted by Rumi'sLeftSock at 1:22 PM on November 24, 2020
emkelly--I am talking to my doc's billing office asking if they take xyz insurance. Then I get, "You'll have to talk to billing. Hold please!" Rinse and repeat. I would agree it is not their job to pick an insurance for me.
posted by Rumi'sLeftSock at 1:22 PM on November 24, 2020
Is your doctor private practice or part of a larger hospital network? If part of a larger network there may be an ombudsperson you can enlist to help you navigate. I'm sorry they are being so evasive and frustrating. We got calls like this all the time and our staff was empowered to answer these questions. (If you MeMail the doctor's website to me, perhaps I can look at it from a different perspective.)
posted by emkelley at 1:29 PM on November 24, 2020 [1 favorite]
posted by emkelley at 1:29 PM on November 24, 2020 [1 favorite]
Beware, one year I checked with my doctor's office on what insurances they took before I selected mine. "Oh yes we take brandname" -- only to find out, on my January visit for a procedure I needed, it turned out they took brandname EXCEPT for ones where the plan started with some certain 3 character code. Which of course turned out to be exactly the insurance plan I had purchased.
This information was all in a binder that the front desk check-in staff had at the ready... they just didn't bother to tell me.
I would not believe what someone tells you on the phone about what insurance they take.
In the past, there has been something on the healthcare.gov site that will let you put in specific medical providers to see if they are on the plan you are considering. Most of the insurance plans I had available to me didn't cover ANY of the major hospitals in my area, so it wasn't entirely helpful. It's a very time consuming tool to use, but it has existed. I haven't yet delved into the site this year.
even though HealthCare.gov's specific insurance I viewed indicated my doc took that particular brand
Oh... whoops I guess that's not useful. I suspect that the answer is that we are all getting **** by the insurance companies no matter what we do, but I'm hoping someone has a less cynical answer.
posted by yohko at 1:40 PM on November 24, 2020
This information was all in a binder that the front desk check-in staff had at the ready... they just didn't bother to tell me.
I would not believe what someone tells you on the phone about what insurance they take.
In the past, there has been something on the healthcare.gov site that will let you put in specific medical providers to see if they are on the plan you are considering. Most of the insurance plans I had available to me didn't cover ANY of the major hospitals in my area, so it wasn't entirely helpful. It's a very time consuming tool to use, but it has existed. I haven't yet delved into the site this year.
even though HealthCare.gov's specific insurance I viewed indicated my doc took that particular brand
Oh... whoops I guess that's not useful. I suspect that the answer is that we are all getting **** by the insurance companies no matter what we do, but I'm hoping someone has a less cynical answer.
posted by yohko at 1:40 PM on November 24, 2020
When I got tired of playing that game, I told the hospital that I had done way more than was reasonable, and that if they chose not to assist me and provide useful information, I would challenge the bill and decline to pay. I'm so, so sorry you're going trough this.
posted by theora55 at 1:55 PM on November 24, 2020 [1 favorite]
posted by theora55 at 1:55 PM on November 24, 2020 [1 favorite]
One thing to try to get out of phone tree hell is to use the online doctor finders for the SPECIFIC plan and network you are considering purchasing. Say you choose Blue Cross but they have two different PPO networks in your area, one is limited and one is bigger. Go to their website, select the plan network and see if your doctor is there.
Also you should rarely pay full price for a visit unless your plan is a strict HMO that offers 0% out of network; if it's a PPO you usually have to cover something like half for going out of network, so if that happens again try to get them to bill your insurance first anyway and see if they pay anything before you kick in.
posted by slow graffiti at 3:41 PM on November 24, 2020
Also you should rarely pay full price for a visit unless your plan is a strict HMO that offers 0% out of network; if it's a PPO you usually have to cover something like half for going out of network, so if that happens again try to get them to bill your insurance first anyway and see if they pay anything before you kick in.
posted by slow graffiti at 3:41 PM on November 24, 2020
Insurance doesn't go by brand, but by NETWORKS and PLANS. Think of it like how your grocery store may carry orange juice, but they may not carry Minute Maid OJ, or they may, but not Minute Made, from concentrate, pulp-free. You need to drill down.
I'm going to assume you've already gone to Healthcare.gov, done your application, and are seeing the options for you/your county. (If you haven't, you have to do this first or you're wasting your time.) Since you want lowered costs, start by filtering to only the Silver plans, which allow you to get subsidies/cost sharing (if available to you). If you don't qualify for subsidies and cost sharing because you make too much, filter for Silver and Gold to get a good sense of your options. But chances are good you'll still want Silver.
Add your two physicians to the filter and look at the plans available. For me, even though I have something like 42 plan options in my county, only two (both Blue Cross, both the two most expensive plans) cover my endocrinologist and my meds. (Yes, you can filter by meds, too.)
You need to note not only the insurance plan/policy name/code, but what NETWORK the plan is in -- for each one you find acceptable. The network may be coded and it may not be immediately obvious to you what the network code stands for.
For example, with Blue Cross Blue Shield of TN, there are 8 different networks (including P, S, Blue Advantage PPO, BlueCare, BlueCarePlus, Blue Essential, Cover Kids, and TennCare Select), but it might not say "Blue Advantage PPO" but BAPPO or whatever. None of these are the plans, these are the networks, and any given plan will fall in one of those networks. Know this information before moving forward, because doctors don't know what plans for which they are providers; their staffers will ONLY know what networks, not what plans.
NETWORKS are key.
Next, armed with the codes and networks for the plans that Healthcare.gov tells you will cover your two physicians, go to the website for the health insurance company or companies offering each of those plans. Each insurance company has a provider list. Look for "find a provider" or "find care" from the PUBLIC-facing part of the carrier's site.
Look under that doctor's name and you should see a list of all networks (for that insurance carrier) that that physician accepts. If you can't tell what network a particular policy is in from the code for the particular plan, call a Healthcare.gov navigator and they'll help. But, for example, my policy is S04S-C. That initial S tells me that my policy/plan in the S network. (Here, different networks let us know whether the network is narrow, wide, or wide across two states because we're on a border.) Every insurance provider has a different way of coding their networks and plan names, so you'll need to cross check Healthcare.gov against the public-facing company websites. (It sounds hard, but it's not. Maybe 10 minutes of work.)
If the NETWORK for the plan you want is a NETWORK in which your doctors are listed, you are covered. A doctor may say, "Yes, we take that company, but not a plan in that network." I've never seen one say, "Yes, we take that company and that network, but not that specific plan."
Again, networks are key.
If you want to go further, you can do as suggested above and:
1) Call the insurance company, explain that you are planning to buy X policy in Y network. Ask if they will verify that Z doctor will be covered by X policy in Y network for 2021.
2) When you talk to the billing department, you need to say, "I need to verify that Dr. Z will be in COMPANY NAME network Y in 2021."
I know you said Healthcare.gov fibbed, but I (gently) suspect, based on your wording, that you had not verified the network and policy, but merely the insurance carrier (what you're calling "brand").
Good luck!
posted by The Wrong Kind of Cheese at 3:50 PM on November 24, 2020 [8 favorites]
I'm going to assume you've already gone to Healthcare.gov, done your application, and are seeing the options for you/your county. (If you haven't, you have to do this first or you're wasting your time.) Since you want lowered costs, start by filtering to only the Silver plans, which allow you to get subsidies/cost sharing (if available to you). If you don't qualify for subsidies and cost sharing because you make too much, filter for Silver and Gold to get a good sense of your options. But chances are good you'll still want Silver.
Add your two physicians to the filter and look at the plans available. For me, even though I have something like 42 plan options in my county, only two (both Blue Cross, both the two most expensive plans) cover my endocrinologist and my meds. (Yes, you can filter by meds, too.)
You need to note not only the insurance plan/policy name/code, but what NETWORK the plan is in -- for each one you find acceptable. The network may be coded and it may not be immediately obvious to you what the network code stands for.
For example, with Blue Cross Blue Shield of TN, there are 8 different networks (including P, S, Blue Advantage PPO, BlueCare, BlueCarePlus, Blue Essential, Cover Kids, and TennCare Select), but it might not say "Blue Advantage PPO" but BAPPO or whatever. None of these are the plans, these are the networks, and any given plan will fall in one of those networks. Know this information before moving forward, because doctors don't know what plans for which they are providers; their staffers will ONLY know what networks, not what plans.
NETWORKS are key.
Next, armed with the codes and networks for the plans that Healthcare.gov tells you will cover your two physicians, go to the website for the health insurance company or companies offering each of those plans. Each insurance company has a provider list. Look for "find a provider" or "find care" from the PUBLIC-facing part of the carrier's site.
Look under that doctor's name and you should see a list of all networks (for that insurance carrier) that that physician accepts. If you can't tell what network a particular policy is in from the code for the particular plan, call a Healthcare.gov navigator and they'll help. But, for example, my policy is S04S-C. That initial S tells me that my policy/plan in the S network. (Here, different networks let us know whether the network is narrow, wide, or wide across two states because we're on a border.) Every insurance provider has a different way of coding their networks and plan names, so you'll need to cross check Healthcare.gov against the public-facing company websites. (It sounds hard, but it's not. Maybe 10 minutes of work.)
If the NETWORK for the plan you want is a NETWORK in which your doctors are listed, you are covered. A doctor may say, "Yes, we take that company, but not a plan in that network." I've never seen one say, "Yes, we take that company and that network, but not that specific plan."
Again, networks are key.
If you want to go further, you can do as suggested above and:
1) Call the insurance company, explain that you are planning to buy X policy in Y network. Ask if they will verify that Z doctor will be covered by X policy in Y network for 2021.
2) When you talk to the billing department, you need to say, "I need to verify that Dr. Z will be in COMPANY NAME network Y in 2021."
I know you said Healthcare.gov fibbed, but I (gently) suspect, based on your wording, that you had not verified the network and policy, but merely the insurance carrier (what you're calling "brand").
Good luck!
posted by The Wrong Kind of Cheese at 3:50 PM on November 24, 2020 [8 favorites]
I should also note, if you see anyone in your doctor's office other than that physician, they may not be covered by that network. My endocrinologist is in eight plans; the PA and the APN are in (the same) four, the other physician in the office is in 7. So, if you ever get asked to see another provider in the same office, you have to ask if they are providers in your same network.
posted by The Wrong Kind of Cheese at 3:53 PM on November 24, 2020
posted by The Wrong Kind of Cheese at 3:53 PM on November 24, 2020
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posted by needs more cowbell at 1:14 PM on November 24, 2020