|
Routine Physical by Out of Network doc
08-20-2015, 12:00 AM
|
#1
|
Full time employment: Posting here.
Join Date: Jul 2004
Posts: 512
|
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!
|
|
|
|
Join the #1 Early Retirement and Financial Independence Forum Today - It's Totally Free!
Are you planning to be financially independent as early as possible so you can live life on your own terms? Discuss successful investing strategies, asset allocation models, tax strategies and other related topics in our online forum community. Our members range from young folks just starting their journey to financial independence, military retirees and even multimillionaires. No matter where you fit in you'll find that Early-Retirement.org is a great community to join. Best of all it's totally FREE!
You are currently viewing our boards as a guest so you have limited access to our community. Please take the time to register and you will gain a lot of great new features including; the ability to participate in discussions, network with our members, see fewer ads, upload photographs, create a retirement blog, send private messages and so much, much more!
|
08-20-2015, 03:49 AM
|
#2
|
Moderator
Join Date: Apr 2012
Location: San Diego
Posts: 14,212
|
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.
__________________
Retired June 2014. No longer an enginerd - now I'm just a nerd.
micro pensions 6%, rental income 20%
|
|
|
08-20-2015, 05:41 AM
|
#4
|
Thinks s/he gets paid by the post
Join Date: Feb 2014
Location: Williston, FL
Posts: 3,925
|
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.
__________________
FIRE no later than 7/5/2016 at 56 (done), securing '16 401K match (done), getting '15 401K match (done), LTI Bonus (done), Perf bonus (done), maxing out 401K (done), picking up 1,000 hours to get another year of pension (done), July 1st benefits (vacation day, healthcare) (done), July 4th holiday. 0 days left. (done) OFFICIALLY RETIRED 7/5/2016!!
|
|
|
08-20-2015, 06:15 AM
|
#5
|
Thinks s/he gets paid by the post
Join Date: Jul 2012
Location: Mississippi
Posts: 1,894
|
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.
|
|
|
08-20-2015, 06:30 AM
|
#6
|
Give me a museum and I'll fill it. (Picasso) Give me a forum ...
Join Date: Jun 2008
Posts: 13,145
|
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.
__________________
Have you ever seen a headstone with these words
"If only I had spent more time at work" ... from "Busy Man" sung by Billy Ray Cyrus
|
|
|
08-20-2015, 09:09 AM
|
#7
|
Give me a museum and I'll fill it. (Picasso) Give me a forum ...
Join Date: Sep 2005
Location: Northern IL
Posts: 26,891
|
Quote:
Originally Posted by rbmrtn
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
|
|
|
08-20-2015, 09:14 AM
|
#8
|
Thinks s/he gets paid by the post
Join Date: Jul 2004
Posts: 1,434
|
Have you tried talking to your doctor about trying to negotiate in-network status with your insurer?
|
|
|
08-20-2015, 07:07 PM
|
#9
|
Full time employment: Posting here.
Join Date: Jul 2004
Posts: 512
|
Quote:
Originally Posted by Tadpole
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.
|
|
|
08-21-2015, 08:09 AM
|
#10
|
Give me a museum and I'll fill it. (Picasso) Give me a forum ...
Join Date: Nov 2010
Location: Sarasota, FL & Vermont
Posts: 36,370
|
Quote:
Originally Posted by Tadpole
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.
__________________
If something cannot endure laughter.... it cannot endure.
Patience is the art of concealing your impatience.
Slow and steady wins the race.
Retired Jan 2012 at age 56
|
|
|
08-21-2015, 08:57 AM
|
#11
|
Recycles dryer sheets
Join Date: Apr 2012
Posts: 216
|
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.
|
|
|
08-21-2015, 09:06 AM
|
#12
|
Moderator Emeritus
Join Date: Sep 2007
Posts: 17,774
|
Quote:
Originally Posted by gindie
...
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.
__________________
“Would you like an adventure now, or would you like to have your tea first?” J.M. Barrie, Peter Pan
|
|
|
08-21-2015, 01:34 PM
|
#13
|
Thinks s/he gets paid by the post
Join Date: Aug 2011
Posts: 3,604
|
Quote:
Originally Posted by MikeWillRetire
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
|
|
|
08-21-2015, 02:04 PM
|
#14
|
Thinks s/he gets paid by the post
Join Date: Jul 2005
Posts: 2,223
|
Just pay the doctor this time, have the labs done in network. Life is short !
|
|
|
08-21-2015, 04:09 PM
|
#15
|
Recycles dryer sheets
Join Date: Apr 2012
Posts: 216
|
Quote:
Originally Posted by gauss
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.
|
|
|
08-21-2015, 07:25 PM
|
#17
|
Full time employment: Posting here.
Join Date: Jul 2004
Posts: 512
|
Quote:
Originally Posted by gindie
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.
|
|
|
|
Currently Active Users Viewing This Thread: 1 (0 members and 1 guests)
|
|
Thread Tools |
|
Display Modes |
Linear Mode
|
Posting Rules
|
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts
HTML code is Off
|
|
|
|
» Recent Threads
|
|
|
|
|
|
|
|
|
|
|
|
|
» Quick Links
|
|
|