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Routine Physical by Out of Network doc
Old 08-20-2015, 01:00 AM   #1
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Routine Physical by Out of Network doc

It is my understanding that Routine Physicals are classified as one of the preventive services that Obamacare requires to be covered 100%.

However, is that the case if they are performed by a doc not in the patient's insurance network?

Background: My wife just switched jobs and became eligible today for her new insurance. Somehow, we must have had a brain f*rt when we were looking up our doctors on the new plan, because tonight our family doc (who we've gone to for 25 years) does not show up as being on it.

There's always the chance that he was dropped since our first search, but for the sake of the questions, let's assume that I did the search wrong!
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Old 08-20-2015, 04:49 AM   #2
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The fact that routine physicals are covered under the ACA is not relevant. The fact that the doctor is out of network of your current insurance is the determining factor.

You have 2 options:
- Have your physical done by an in-network doctor OR
- pay the hit for out of network.
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Old 08-20-2015, 06:20 AM   #3
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If the service is performed by an out-of-network provider when an in-network provider is available to perform the preventive service, insurers may charge patients for the office visit and the preventive service. However, if an out-of network provider is used because there is no in-network provider able to provide the service then cost-sharing cannot be charged.
Source: Preventive Services Covered by Private Health Plans under the Affordable Care Act | The Henry J. Kaiser Family Foundation
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Old 08-20-2015, 06:41 AM   #4
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It doesn't mean the doctor cannot charge for the 100% covered services, it means insurance has to cover the physical.

The insurance company has already said, with its network list, what doctors are covered.

My guess, is no coverage for a 100% covered service, performed out of network.
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Old 08-20-2015, 07:15 AM   #5
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If you looked up the doc with the online search, that may be an issue. What I have seen is the online listing many times are not current. Many times the Drs don't even know what plans they are in. Probably call their billing office and the insurance plan to verfy.
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Old 08-20-2015, 07:30 AM   #6
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A similar thing happened to me last year. Well, when I signed up my doctor was in network. But he must have been dropped at the time of the physical. At least most of the lab work was in-network.
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Old 08-20-2015, 10:09 AM   #7
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Originally Posted by rbmrtn View Post
If you looked up the doc with the online search, that may be an issue. What I have seen is the online listing many times are not current. Many times the Drs don't even know what plans they are in. Probably call their billing office and the insurance plan to verfy.
I got this run around when I had to switch from my MegaCorp retiree covered insurance to 'the exchange' (partly subsidized by MegaCorp).

My old doc was only in some very expensive plans. I found docs with good refs, and the web site showed they were in the plans I considered. All good, right? Wrong. I try to make an appointment, and they tell me I'm not in their network. WTH?

It was only by dealing with our MegaCorp's support staff (they hired an advisor group to walk us through this) that it got straightened out - some glitch in the way that doctor's group was listed. I can't even explain it - all the doctors were on the web site as 'in network', at that address, but they had to be listed as part of some physician's group, and they were under some other group name in the listing?

I was told that these listings can change at any time w/o notice. What am I supposed to do? Check, then make an appointment, and then check again 10 minutes before I go in? How is a working person supposed to have time and resources to tackle this crazy maze?

-ERD50
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Old 08-20-2015, 10:14 AM   #8
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Have you tried talking to your doctor about trying to negotiate in-network status with your insurer?
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Old 08-20-2015, 08:07 PM   #9
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Have you tried talking to your doctor about trying to negotiate in-network status with your insurer?
Intend to talk with their billing department tomorrow. Thanks for the suggestion.
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Old 08-21-2015, 09:09 AM   #10
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Have you tried talking to your doctor about trying to negotiate in-network status with your insurer?
Or see if the doc will accept what your insurance pays for in-network physicals and then see if the insurer will agree to pay their in-network amount to the doc or reimburse you for the cost as a one-off concession.
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Old 08-21-2015, 09:57 AM   #11
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I had a physical a few months back, and I ended up having to pay $400, mostly due to lab expenses. My doctor is a preferred provider in my plan, so I wasn't expecting that bill.
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Old 08-21-2015, 10:06 AM   #12
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Originally Posted by gindie View Post
...

Background: My wife just switched jobs and became eligible today for her new insurance. Somehow, we must have had a brain f*rt when we were looking up our doctors on the new plan, because tonight our family doc (who we've gone to for 25 years) does not show up as being on it.
...
Maybe her new insurance is saving your family some money that you could see as offsetting the cost of going to the out-of-network family doc. I would also check on the coverage of tests and labs that the family doc might order--can they be done somewhere that is in-network so they will they be covered even if ordered by an out-of-network doctor?

If you have had the same family doctor for 25 years, he might be thinking of retiring, of course--maybe he reads these boards . Checking out the in-network doctors for a possible new doctor might not be a bad idea.
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Old 08-21-2015, 02:34 PM   #13
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I had a physical a few months back, and I ended up having to pay $400, mostly due to lab expenses. My doctor is a preferred provider in my plan, so I wasn't expecting that bill.
Were the lab expense due to medical diagnostics/ medical treatment or were they standard screening tests?

If they were standard screening tests then I think you should have not been billed as generally they are required to be covered by ACA.

I went through a round of this in January when we got all sorts of lab bills that I thought should have been covered. In the end I got them all reversed and paid by the insurance company (except for one).

The most interesting case was that the industry changed the billing codes for pap-smear related tests for DW this year. Her employer provides the insurance company a list of codes that they cover AND DID NOT update the list to the new codes. This one took much effort to track down the root cause and convince them there was a problem.

Bottom line, know which tests should be included (deductible free) and which ones are not.

-gauss
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Old 08-21-2015, 03:04 PM   #14
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Just pay the doctor this time, have the labs done in network. Life is short !
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Old 08-21-2015, 05:09 PM   #15
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Originally Posted by gauss View Post
Were the lab expense due to medical diagnostics/ medical treatment or were they standard screening tests?

If they were standard screening tests then I think you should have not been billed as generally they are required to be covered by ACA.

I went through a round of this in January when we got all sorts of lab bills that I thought should have been covered. In the end I got them all reversed and paid by the insurance company (except for one).

-gauss
I thought they were routine blood and urine tests for a physical, but there were 16 of them. Things like insulin level, lipid profile, uric acid level, vitamin D, etc. Unfortunately, I got frustrated just trying to understand the "summary of benefits" from the insurance company, so I just paid it.
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Old 08-21-2015, 06:42 PM   #16
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The link below lists the covered preventive services under the ACA. An insurer may add additional services to the list but the basic list includes few lab tests.

Link: Preventive Services Covered Under the Affordable Care Act | HHS.gov/healthcare
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Old 08-21-2015, 08:25 PM   #17
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Intend to talk with their billing department tomorrow. Thanks for the suggestion.
I called the doctor's billing department, and they gave me their tax id that they use for billing.

Called the insurance with that info and they said the doc is in network. However, she got the same out-of-network message I received when she also tried the web interface. She couldn't explain that.
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