Doctor Networks: 3 Tips to Finding an In-Network Provider
One of the main questions you may have while shopping for a health plan is who your doctor will be. If you already have a doctor you love, you might be wondering how to find a plan that your doctor takes. To find these answers, it helps to understand terms such as HMO, PPO, and EPO, as well as the phrase “doctor network.”
Let’s break down these terms and tackle a few other provider-related health insurance questions so you know how to find (or keep) a great doctor or other in-network provider.
What is a doctor network?
A doctor network, also referred to as a provider network, is a list of hospitals, doctors, nurses, and other health care providers that a specific insurance plan contracts with — known as “in-network” providers. These providers have agreed to accept payment from the health plan at prices both sides agree to. It’s how health plans keep costs low for you while ensuring you get the care you need.
It’s also why, if you receive care from a doctor that’s out-of-network, your plan might cover fewer (or none) of the costs from that visit. Different types of plan networks cover services from out-of-network providers differently. Some might offer partial coverage, while others might not.
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Types of plan networks explained
There are four primary types of plan networks that you’ll encounter as you shop around for a plan. As you learn more about these, be sure to think about which would best suit your needs.
HMOs cover you only if you see an in-network provider. These plans also require that your primary care physician refer you to any specialists (like a cardiologist).
PPOs often have more expensive monthly payments (also called premiums), but offer partial coverage if you go out-of-network. They don't require referrals to see specialists.
EPOs also cover you only if you stay in-network, but you can see specialists without referrals. Think of them as hybrid of an HMO and a PPO.
POSs offer partial coverage if you go out-of-network, but require referrals to see specialists. POSs are also a hybrid of an HMO and PPO.
How do I know if my provider is in my network? 3 ways to check
With all of this talk about staying in-network, you are probably wondering how to actually check if a provider is in-network with a health insurance plan. While doctor networks aren’t always as straightforward as we’d like them to be, we’ve outlined three simple options you can use to make sure you see an in-network provider that you love.
Insider tip: Before you check to see if your provider is in-network, make sure you’re familiar with the plan name, metal tier, and network type. This should all be available on your insurance card or Stride’s website if you’re still evaluating plans.
Call the provider’s office. Not every doctor at a medical practice will accept the same insurance, so make sure you have the specific name of your health plan and the specific name of your doctor when you call. The best way to ask is by saying “I would like to check if Dr. John Doe is in-network with Blue Shield Gold 80 PPO.”
Further, be sure to tell your doctor’s office whether or not you have a marketplace plan (you know you have a marketplace plan if you qualify for a government subsidy) because providers sometimes won’t accept marketplace plans. By getting specific, you can help ensure that you are getting the most accurate information (and don’t end up with a surprise bill down the road).
Insider tip: Doctors often practice at different facilities, and not all locations will be covered by your plan, so make sure your visit is at the right office. If you receive a surprise bill for an out-of-network visit, there’s a chance your doctor just put the wrong location on the paperwork.
If you can’t get an answer by calling the provider’s office, don’t fret….
Call the insurance company. Insurers can check whether a specific provider is in-network by looking up their specific tax ID number. You can get this number by first calling your provider’s office, then calling the insurance company’s general number (you can find this with a quick Google search of “[insurance carrier] customer service phone number”). Let them know you want to check whether a provider is in-network and give them both the specific plan name you are referencing and the doctor’s tax ID number. They should be able to confirm whether or not the provider is in-network.
Do some online digging. Most health insurance companies have a “find your doctor” option on their website that lists which doctors are covered by which plans. Here are the doctor search pages for a few common companies:
You can search by name to see if your doctor is an in-network provider. On the other hand, if you are looking for a new provider, use the online directory to search for a doctor in your area that is in-network.
I recently lost my employer coverage. Can I still see the same doctor?
It depends. If you’ve recently lost your employer-sponsored health insurance and are looking to enroll in a new plan during the Special Enrollment Period, it’s always a good idea to check to make sure your doctor accepts your new plan before you enroll. To do this, follow the three steps listed above.
What happens if I see an out-of-network provider?
It depends on which type of plan network you have. PPOs and POSs will likely cover a portion of your visit, though the exact percentage will vary since out-of-network benefits are different across plans. In contrast, HMOs and EPOs will not help cover your out-of-network visit.
While we recommend seeing an in-network provider whenever possible, we understand accidents and emergencies happen. If you saw an out-of-network provider and want to try to avoid those costs, we have a few tips for you.
If you end up being charged for an out-of-network visit, you may be able to appeal, especially if you can prove the visit was medically necessary and you couldn’t get the care you needed in-network.
If your doctor leaves your network, they should notify you, and you may be required to find a new doctor. However, some companies like Blue Cross Blue Shield will let you continue to see the doctor in special circumstances (like if you’re in the second or third trimester of pregnancy or are being treated for a terminal illness).
Have more questions? Don't sweat it. Email us at support@stridehealth.com and we will help you get things figured out. Or, if you’re ready to start comparing plans, enter your ZIP code below.