Why do most health plans have a network of doctors?
Health insurance plans usually feature a network of providers. That includes both health care professionals – doctors, psychologists, physical therapists, among others – and health care facilities, such as hospitals, clinics and pharmacies.
The insurance company organizes the network – or contracts with an existing one – as a way to manage costs. The insurance company contracts with network providers to get a discounted price for certain services and assigns the plan’s members to network providers. Health plans usually offer insured members a financial incentive to encourage you to use “in-network,” “preferred” or “participating” providers. Or they can charge extra for coverage if you go outside the network.
Why does it matter if I go to a doctor who is not in my health plan’s network?
If a doctor is not in the provider network, the health plan will not get a discount on medical services. Because it has to pay more for those services, the insurance company structures your benefits to discourage you from going out-of-network, which results in you paying a much of higher cost for services when you do.
How much more will I pay to go to an out-of-network physician?
That depends on the type of health plan and the specific plan, so check the details on out-of-network coverage.
In general, Health Maintenance Organizations (HMOs) restrict coverage to network providers. If you use a doctor or any other provider not in the network, you may have to pay the full cost of those medical services.
Preferred Provider Organizations (PPOs) plans typically provide coverage of your care from a non-network provider, but you’ll pay a higher share of the costs. Benefits vary from plan to plan, but you might be charged a higher copayment, a higher coinsurance percentage, a combination of higher copayment plus coinsurance, or the difference between the negotiated fee for network providers and the amount charged by the non-network physician.
How do I check whether my doctor is in a health plan’s network?
Here are three quick options:
- Visit your health plan’s website and you can access its directory of network providers.
- Call the health insurance company. The phone number for customer service appears on the health plan’s website or on your insurance card.
- Call your doctor’s office. The office staff can tell you which health plans the doctor accepts.
Because insurance companies can have different networks for different plans, make sure you search the provider network by your specific plan.
When choosing a health plan, what role should the provider network play?
The health insurance coverage you select determines your selection of doctors and hospitals. For that reason, experts recommend picking your providers before you pick your insurance plan. You can make a list of all the doctors you use and want to continue using. If you need family coverage, add your dependents’ doctors to the list. Add your choice of hospitals. Then narrow the field of health plans to the ones that include your preferred providers in their network.
How should I choose a doctor, whether I need a primary-care physician, specialist or dentist?
Start by asking friends, family members and other doctors for a recommendation. Then research doctors’ experience and credentials. You want a doctor who is board-certified in the medical specialty that treats your condition. That means the doctor has the necessary training, skills and experience.
For more information, see Consumer Reports recommendations on How to Choose a Doctor.
Is it OK to change doctors?
Absolutely. You have the right to choose any available primary-care physician from your health insurance company’s provider network. One recent study found that 15 percent of patients switched to a different doctor in a two-year span.
What should I do if I am referred to a specialist who is not part of the network?
You can ask the referring physician to recommend a specialist in your specific network. In metropolitan areas with a large provider network, a comparable alternative is usually available.
In smaller markets and in certain specialties or subspecialties, an out-of-network specialist may be the only option or may be uniquely qualified to treat a certain condition. In that case, it never hurts to ask your health insurance company to grant an exception. If the plan denies your request for coverage, you have the right to appeal the decision and have it reviewed by a third party.