How do I figure out what actual medical providers are available to me?
September 18, 2023 1:58 PM   Subscribe

Using PCP referral, health insurance search, and Zoc Doc search yields me different results. How can I actually find a provider/appointment without tearing my hair out?

My primary care physician has referred to me to a (common) specialist after some abnormal lab results. I was referred to Major Medical Network (Mount Sinai in NY), but after calling them they don't have a specialist appointment until December.

So I went to my health insurance website (BCBS) to look up other providers, but seeing very few in my desired location. Doctors at Mount Sinai were not included in the search results, even though I already verified with Mount Sinai that they accept my insurance in-network. I'm fine to consider doctors outside of that network but maybe wanna try them first?

I then went to Zoc Doc and punched in my insurance info, and got an entirely different selection of doctors. There were some Mount Sinai doctors in the needed specialty that show availability as early as two weeks from now.

So like, what should I be doing?
Triple confirming with Mount Sinai that they take my insurance even though they don't show up on my insurance website?
Booking an appointment through Zoc Doc even though calling Mount Sinai directly didn't yield me earlier appointments?

Also, I'd love an insider/experienced explanation for why this is so I can figure out a more efficient way to book appointments since American health care is a f*cking nightmare. I've been lucky enough to not have to require much specialist care in my life, but I gotta figure out a better way to manage this as I careen toward middle age.

posted by greta simone to Health & Fitness (10 answers total) 3 users marked this as a favorite
ZocDoc is not reliable as a guide to insurance; that's certain.

It is not necessarily the case that every doctor in a particular services network takes the same insurances. In particular, just because physicians employed by one of the Mt. Sinai hospitals take an insurance does not mean that an affiliated practice group will. If you want to be confident, you need to confirm with both the doctor's office (by phone or email) and at least the insurance website.

I'm a little surprised to hear that BCBS is not returning any Mt. Sinai affiliated physicians, unless you have some extremely bargain-basement plan. In my experience, the doctor search interfaces on insurance websites are obtuse and look as if they were designed in 2003. Are you quite sure you searched correctly?

Welcome to the stupidity.
posted by praemunire at 2:21 PM on September 18

No advice on what to do, sorry. Where I live, I have to tell people to call each individual doctor's office and ask them if they take your specific plan. It's a nightmare.

New York has this protection for New York regulated plans (i.e., probably no Medicare, because that's purely federal):

Right to Go Out-of-Network When Your Health Plan Does Not Have An In-Network Provider:

You may get a referral or authorization to an out-of-network provider when your health plan does not have an in-network provider with the appropriate training and experience to meet your health care needs. This will be at no additional cost beyond what you would pay to see an in-network provider.
Contact your health plan to receive information on how to get a referral or authorization to an out-of-network provider.

As for what's going on, this is a best guess rather than a true insider view; I do have related knowledge.

So, no surprise, insurance companies appear to be an absolute nightmare to work with for most doctors and provider groups, such that inflow and outflow out of various insurance companies appears to be fairly common. Practices will contract with a given insurance or kind of insurance and then have to stop. The compliance rules are changing all the time. Errors are expensive and insurance denials are expensive to fight. Practices are also being bought out in a consolidated conglomerate way by hospital groups, which will have their own insurance acceptance policies.

Insurance companies are required to maintain up to date databases of what doctors are on their insurance, but this task is very difficult given the frequent changes, and providers don't always in fact tell insurance companies what their current information is. Also companies can also be penalized by various regulators for not having the right kinds or amount of specialists on their databases, but are very rarely penalized for just having crappy databases. So it works out to a vast "ghost network" problem. See, e.g.

Which is annoying more than anything, just delay-causing, when there isn't a critical doctor shortage! But on top of that, there is, in fact, a critical doctor shortage. If there's only one doctor who actually practices X in the area and they're not taking your insurance, that's a big issue, and there's no way to check when you're shopping for insurance, because of ghost networks!
posted by peppercorn at 2:30 PM on September 18 [1 favorite]

Response by poster: @praemunire I have the best plan my employer provides, a PPO, not budget to my bank account, that's for sure.

And yes definitely searched correctly, just double checked. The doctors through the BCBS portal don't show what affiliate practice group or hospital they are with, but neither of the locations Mount Sinai is trying to book me for in December even show up on the BCBS list when looking at map view. I'm able to schedule through Mount Sinai for a December appointment, but then Zoc Doc showed other Mount Sinai (hospital? affiliate practice? no idea, didn't say) in my speciality with availability end of this month.

How do I know when I call Mount Sinai if they are searching hospitals or affiliated practice groups when trying to schedule?

Losing my mind.
posted by greta simone at 2:40 PM on September 18

What # are you calling when you call Mt. Sinai?
posted by praemunire at 2:46 PM on September 18

Using insurance coverage look up tools can be tricky, in my experience. Looking up institutions can be doubly tricky because they may be listed under various names. I would suggest looking up individual providers (the specialists you are seeking to see) by name on the BCBS portal, if you haven't tried that yet. Are the doctors in that practice listed as covered providers? If so, that should be reassuring. If you still can't find them, I would call your insurer to get to the bottom of the matter.
posted by reren at 2:51 PM on September 18 [2 favorites]

Unfortunately, this is just something where there really isn't good data that exists, to some extent. The relationship between doctors and hospitals can be really complex, there are a mind-boggling array of different insurance plans even within the same carrier, and it's a total mess.

I recently worked somewhere that was trying to add information about which doctors take which insurance, and there's no canonical up-to-date information that's available in any practical sense. We paid big bucks to a data broker for pretty incomplete and questionably up-to-date information, did our best to combine that with data scraped from hospital websites, and generally weren't able to get a reliable answer even though our users were the doctors themselves and wanted that information available.

I think ZocDoc is definitely going to be pretty unreliable in terms of insurance coverage information, but also, unfortunately, in appointment availability as well. I've often had the experience of scheduling a specific appointment there, then gotten a call back from the actual doctor's office to reschedule because that particular type of appointment can't go in that particular time slot, or some other esoteric reason.
posted by duien at 2:57 PM on September 18 [2 favorites]

This happens, or something similar enough, to my BCBSIL searches. For some reason it won't pull up people near wherever I search if I just put in the kind of doctor I was looking for+location. Maybe they had some kind of metric for prioritizing different providers, but I really don't know.

But if I looked up a specific provider by their name, it would show if they were in or out of network. The search still wasn't great. I think I frequently had to turn off almost all filters (although I was looking for a PCP, maybe it's better for specialists) and just type in last name, then look at the map and zoom into the area around their office.

So, annoying. But around here BCBSIL is so common that usually it's not an issue, that may not apply everywhere. I basically Google to see who I may want to go to, then enter the name in the BCBS search, then call the office of the provider (as directly as I can. So if it's a hospital and I need an ENT, I try to call the ENT office directly, sometimes I have to hunt a bit for the number) to confirm. I think they were almost always in agreement, but one time they let me know they were dropping my plan in a month or so (good to know!).

Possibly (likely?) less relevant: I work for a university associated with a health system, and some of the providers have reduced co-pays if I go to them. Directions are explicit that we have to not log in to search for those providers. They didn't make this information blatantly obvious on the stuff sent to me when I enrolled, but the university benefits website has explicit directions. If your employer has a benefits page that you haven't checked out, it may be worth it to see if there's some weird trick for your plan.
posted by ghost phoneme at 3:15 PM on September 18

A couple of enraging pitfalls to watch out for: BCBS deliberately uses an online search function that is catastrophically bad and makes it hard to do a very simple search unless you use precisely the correct search terms. The second pitfall when you do call doctor’s offices is to ask if the provider is “in network,” those specific words. If you, a PPO holder, ask if someone takes your insurance, they will cheerfully tell you that they do, but they will not mention that you will be on the hook for a far bigger percentage of the cost than you would with an in-network provider.

I’m so sorry you’re dealing with this!
posted by corey flood at 4:46 PM on September 18 [1 favorite]

For BCBS, you can send them a message via their app or website. I have done that before to confirm the cost of a service or if a provider was in network. They've actually responded with helpful confirmation and it makes me feel better because I have it documented in the message (versus, so-so told me over the phone it would cost $X). It does take them a few days to respond if you're in a rush and I try to be super detailed with questions to catch any loopholes.
posted by inevitability at 5:07 PM on September 18 [1 favorite]

I have BCBS and have seen several doctors who were definitely in-network but who were not listed in the directory at all, even when I searched for them directly by name. In my experience, calling the individual doctor’s office and asking if they are in-network for me is the only way to know.
posted by CtrlAltDelete at 9:04 PM on September 18

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