Health - Coping with Managed Care

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If you are a part of a managed care health insurance plan, such as a PPO or HMO plan, you are probably familiar with the terms "in-network" and "out-of-network".

It is important to realize that the network provider list is subject to change at any time.  It is the insured's responsibility to keep up to date with the in-network providers.  This can be a big task, but in the end you won't regret doing a little extra work.

If you are enrolled to a PPO plan and use a doctor who is not part of the network you may be subject to a hefty additional out of pocket expense.  If you are enrolled to an HMO plan, you may not be provided with any coverage for services performed by an out-of-network provider.

You can prevent this from happening.  Never trust a provider book, once again, the list can change at any time, without notice.  We suggest that you do one of the following:

• Search your PPO/HMO network's website.
• Call your insurance company direct for provider approval. (Most Dependable)


• Call your doctor's billing department

These three are your most reliable source to ensure the provider is still active in the network.  We most suggest calling the insurance company for direct approval.  If you use this method the insurance company can cooridinate your whole visit with the facility.  You may ask, "Why would I want approval on the whole visit?", For example: You are scheduled for a surgery, the surgeon may be included in the network, but the anesthesiologist may not be, which would make you responsible for out-of-network charges from the anesthesiologist.  If you allow the insurance company to cooridinate the visit, they will likely set your appointment time up with a network affiliated anesthesiologist is available.

If you have a favorite long time family doctor, but find that the doctor is not included in the network, you can refer the doctor to the network.  Either have the doctor contact the network and complete the necessary steps to join the network or simply call your network and have them contact the doctor.  This may take some time, but is often successful.