How to Check if a Doctor is in Network: How to Verify Networks and Find an In-Network Doctor
What is a health network?
Before we get into how to find out if a doctor is in your network, let’s break down some basic definitions, starting with “health network.”
When you hear the term “health network,” it is a reference to everything that your insurer is connected with. This might include:
- Facilities (including hospitals, long-term care facilities, etc.)
- Suppliers (of things like prescription medication and medical equipment)
- Providers (such as doctors, nurses, and other health professionals)
If these entities are within your insurer’s network, it means that they are contracted to provide services that are covered by your provider. In other words, you are only covered for medical services that are provided by facilities, suppliers, and providers that are within your insurer’s network.
Obviously, this means that you should do everything in your power to visit providers that are within your network. If you visit providers that are out of your network, you will incur higher costs. This is why many patients in the United States try to check if a doctor’s within their network before figuring out whether to visit them for appointments.
Why networks can be confusing.
That being said, some insurance plans may cover out-of-network services – but not all. Others may only cover a certain percentage of the costs. Generally speaking, all insurance plans provide coverage for emergency out-of-network coverage. For example, you might be traveling through a different state when a car crash occurs, forcing you to visit a local hospital that is out of your network. Fortunately, your insurer will not penalize you for this.
In addition, your insurer may provide coverage for out-of-network providers if those services are unavailable within your network. Essentially, insurers want to keep you within your network unless there’s absolutely no other choice. After all, insurance companies are businesses, and their goal is to earn as much profit as possible. If they cover you for services provided by healthcare organizations that are not under contract, they typically lose money.
The most frustrating part about all of this is that your insurer will often offer virtually no assistance when it comes to finding out which providers are within your network. This is considered your responsibility. Many patients make the mistake of simply assuming that a particular provider is within their network – only to get a nasty surprise later when they’re forced to pay the entire bill. As a general rule, it’s always a good idea to call your insurer to confirm that a provider is within your network before moving forward.
The phrase “health network” often gets confused with the concept of a “hospital network.” These are actually two different things. A hospital network is basically just a health care system with two or more hospitals under its umbrella. These organizations may be public, nonprofit, or for-profit in terms of their structure. Despite its name, a hospital network may provide a range of services – not just hospitals. These networks are not necessarily associated with the health insurance industry or “health networks” in the context of health insurance. Hospital networks have been around long before the rise of healthcare in the United States, and the earliest examples of these organizations can be traced back to the Greeks and the Romans. In the middle ages, the Knights Hospitaller become one of the well-known hospital networks.
With all that said, some of the largest hospital networks are run for profit, and they exist within the United States's private healthcare system. HCA Healthcare, for example, offers almost 50,000 hospital beds – more than any other hospital network in the world. The Veterans Health Administration is another example of a record-setting hospital network in the United States, having the most staff members with over 330,000 individuals.
Different plans offer different types of networks:
- Exclusive Provider Organization: Also known simply as an “EPO,” an exclusive provider organization only offers cost-sharing coverage for providers within the predetermined network. When you choose an EPO, you must pay the full cost of your medical expenses unless you visit providers within your network. But as previously mentioned, you are always covered in the case of an emergency.
- Preferred Provider Organization: Otherwise known as a “PPO,” a preferred provider organization also gives you cost-sharing benefits if you visit providers within the network. However, it also gives you some cost-sharing assistance if you visit providers outside of the network. For this reason, a PPO is generally recommended if you place a higher value on freedom of choice. It also allows you to visit specialists without first getting a referral from your primary care provider.
- Point of Service: A “POS” or point-of-service plan allows you to pay less for visiting providers within your network – just like PPO and EPO plans. However, you will also have the opportunity to visit providers outside of your network at a discounted rate. This results in a higher monthly premium for a slightly more flexible plan.
- Health Maintenance Organization: Another common type of plan is called a health maintenance organization – or “HMO.” With this plan, you’ll only receive coverage for visiting providers within your network. So what’s the difference between an HMO and an EPO? HMOs are unique because they often include wellness programs, prevention programs, and other forms of integrated care. HMOs also represent the cheapest option for health insurance.
As you can see, your network may change somewhat depending on which plan you choose. In addition, some plans make it easier to visit providers outside of your network. Keep these factors in mind when you choose not only your health insurance provider, but also your specific type of plan.
How do I determine which networks my doctor is in?
The first step is to make a list of every provider you use on a regular basis. This might include your primary care provider, your local hospital, your local pharmacy, and perhaps providers for services such as chiropractic care or physiotherapy. Once you have a complete list to work with, consider calling your insurance provider and checking whether or not they are within the network.
You can also visit healthcare.gov to compare and contrast insurance providers. This page also allows you to search for specific providers, such as your primary care provider or local pharmacy. If you go down your list and search all of your providers, you should be able to see which networks they’re part of on this government website.
If you accidentally sign up for an insurance plan that doesn’t include your doctor in its network, it’s important to switch to a new plan as quickly as possible. You are allowed to switch plans before the date that your coverage begins. If you wait too long to cancel your plan, you may be left with a gap in your coverage. Fortunately, there are many options that allow you to cover this gap with a short-term insurance alternative – such as CrowdHealth.
Another option is to contact your insurance provider and request that your doctor be considered in-network. Sometimes, certain exceptions are granted – so it’s definitely worth trying.
Why do doctors choose a specific network?
Doctors may choose specific networks for a range of reasons. If you discover that your chosen primary care provider has chosen a specific network, they might have made this decision based on career incentives. For example, they might have been offered a higher wage with a network that your provider doesn’t cover. Your provider’s network isn’t “bad” or sub-par just because your doctor chose a different network.
They might have chosen to work in a specific geographic area because they enjoy the neighborhood. Perhaps they’d rather live in a rural setting than a big city. Maybe they have chosen a facility with fewer patients in an effort to make their job easier. For the most part, doctors choose career paths based on their best interests – not because a certain network is inherently better or worse.
How does this affect my health insurance plan?
Your network of choice affects your health insurance plan in many ways. You will need to choose an insurance provider with a network that contains your targeted healthcare providers – whether that’s a family doctor, a chiropractor, a pharmacy, a rehab center, and so on. Your goal is to choose a health insurance plan that contains as many of your chosen providers as possible.
Of course, a traditional health insurance plan isn’t your only option for healthcare coverage. You can also opt for one of the many health insurance alternatives, such as CrowdHealth. One of the main benefits of choosing this particular option is that you no longer have to worry about doctor networks. This healthcare funding option works in a different way, and networks do not factor into the overall system. The basis of this strategy is crowdfunding, which means that you pay a monthly fee to receive coverage for your medical bills.
All you really need to do is visit any doctor, pay your medical bills, and then upload the receipt to the CrowdHealth app. From there, CrowdHealth will facilitate member funding, allowing your medical bill to be crowdfunded smoothly and easily. If your medical bill costs more than $500, you only need to pay the first $500. For the remainder, you can submit a crowdfunding request quickly and easily with CrowdHealth.
But the lack of doctor networks isn’t the only benefit associated with CrowdHealth. This option also offers $0 deductibles, unlimited virtual health services, unlimited talk therapy, discounted prescriptions, personal care advocacy, and much more. CrowdHealth will even negotiate on your behalf, lowering your medicals even further. A single male in his 30s can expect to pay about $175 per month with CrowdHealth, while an equivalent health insurance plan would cost him more than double that.
But why don’t CrowdHealth members need to worry about doctor networks? Basically, the only reason these networks exist is that certain insurers have existing contracts with certain networks. These contracts help both parties agree on prices, giving insurers more stability and predictability while providing networks with plenty of new customers. CrowdHealth doesn’t have any of these contracts with networks, so each case is handled on a fair, case-by-case basis that ensures total flexibility and affordability.
If you’d like to get started with CrowdHealth and forget about doctor networks altogether, you can begin the process today. Contact CrowdHealth’s knowledgeable, helpful team members who can answer all the questions you may have as you take the plunge.
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