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Why Doesn't My Health Insurance Cover the Doctors I Want to See?

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Updated March 24, 2012

Question: Why Doesn't My Health Insurance Cover the Doctors I Want to See?
There may come a time when you want to see a certain doctor, or receive care at a certain hospital or be tested at a particular lab, but those providers or facilities are not covered by your health insurance company. Why do some health insurers refuse to pay for some doctors or facilities?
Answer:

This is actually the flip side of the question, "Why don't some doctors accept my insurance?" The answer has to do with reimbursements, the cost of doing business, and "follow the money."

If we understand how health insurance works, it's easier to understand why your insurance company won't cover all the doctors you'd like to see.

Each year, doctors and healthcare facilities like testing labs, hospitals, and others, negotiate pricing with health insurers and payers. In its simplest form, it goes like this:

Doctor: When a patient with diabetes visits my office, I charge $100 for the visit, and $75 for the blood work.

Payer: That's too much money. We'll pay you $55 for the visit and $35 for the blood work.

Doctor: I can't pay my staff or keep my lights turned on for that paltry amount! How about $85 for the visit and $50 for the blood work?

Payer: Sorry. We are unwilling to pay you those amounts.

Doctor: Then I am unwilling to work with patients who have one of your insurance plans.

Some insurance companies refuse to pay some doctors the amount those doctors believe they are entitled to be paid. When that happens, the doctor will either be designated as "Out of Network" (see below) or will stop accepting that form of insurance all together.

In Network doctors are those who accept your insurance, plus a relatively low co-pay as their complete payment.

Out of Network doctors are those who will accept your insurance as partial payment. You will either pay a much higher co-pay to see them, or you will be billed for the balance of what they ordinarily charge.

What can you do to be sure your insurance will pay for the doctors you want to see?

  • If the doctors you want to see are more important to you than what it costs to visit them, then contact their offices and ask which insurance payers they will accept reimbursement from, either in-network or out-of-network. Then choose from among the plans they accept. It's possible they work with only some plans from an insurer, and not all, so be sure to ask them to list which plans are acceptable.
  • If you are limited to only some insurers or some plans, then check with those plans to see which doctors are on their lists of providers. This information is often found on the payer's websites, or you can call their customer service phone numbers to ask.
  • During the open enrollment period each year, usually in November or December, be sure to follow the steps to choose the right health insurance plan for you.
  • There are additional options, depending on how the doctor's practice is administered.

Learn Why "Follow the Money" Is the Answer to More Health Insurance Questions:

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