Seeing a Doctor Out-Of-Network

[scrabbler1]

I have a HI plan through the New York Marketplace Exchange (ACA Silver Plan) With OSCAR insurance company. I learned last week that some of my doctors will not be in the Oscar network in 2017 because Oscar is forming its own network.

While most of my doctors who will no longer be in Oscar's network next year aren't crucial because they treated me for temporary ailments since resolved, or are doctors I see rarely so I can easily find another one within the Oscar network, one doctor being dropped I don't really want to lose if I can help it. He's my endocrinologist for my recently diagnosed (in 2015) Type 2 Diabetes.

I see three viable options.

(1) I can switch to a new endocrinologist who is within the Oscar network for 2017. I found a few names and have been looking them on line to see what kind of reviews and have as well as their experience and educational background. One seems rather promising.

(2) I can switch to new insurance company which has my current endocrinologist in their network. I will see my current endocrinologist in a few weeks so I can get names of other networks he is in. The only catch there is that I see two other doctors (specialists) so they would have to be in the network, too. I encountered this obstacle when left my previous insurance company at the start of 2016 after being dissatisfied with them. I also need to make sure the new IC has a good prescription drug plan, one which doesn't use that awful mail-order outfit Express Scripts. I have been quite happy with Oscar this year. They have good customer service and a good website, along with a reasonable premium. I'd hate to give them up.

(3) I can arrange to see my current endocrinologist out-of-network. This would cost me a few more bucks but it is this option I want to know if any of you have tried. Suppose I agreed to pay my current endocrinologist the same amount he gets paid by Oscar and me combined (i.e. copay + Oscar's payment, most of which is my copay)? Is this something a doctor might go for, as opposed to wanting me to pay his much higher, provider-charged rate as shown in the EOBs I see? I'd have to see him only twice a year and I haven't had any changes to my meds since early January so it's been mostly maintenance work for him.

From his perspective, he'd either get paid in-network from an IC or get paid out-of-network and get paid the same thing by me. Am I missing something?

 

[bingybear]

I have a HI plan through the New York Marketplace Exchange (ACA Silver Plan) With OSCAR insurance company. I learned last week that some of my doctors will not be in the Oscar network in 2017 because Oscar is forming its own network.

...

(3) I can arrange to see my current endocrinologist out-of-network. This would cost me a few more bucks but it is this option I want to know if any of you have tried. Suppose I agreed to pay my current endocrinologist the same amount he gets paid by Oscar and me combined (i.e. copay + Oscar's payment, most of which is my copay)? Is this something a doctor might go for, as opposed to wanting me to pay his much higher, provider-charged rate as shown in the EOBs I see? I'd have to see him only twice a year and I haven't had any changes to my meds since early January so it's been mostly maintenance work for him.

From his perspective, he'd either get paid in-network from an IC or get paid out-of-network and get paid the same thing by me. Am I missing something?

The bold... is sounds like you have already talked with him and he is in agreement. But earlier is sounds like you are asking if he might do this arrangement.

A doctor might. The difficulty from his standpoint is he would likely be running your case (billing wise) completely differently than all his other patients. This may be an issue as it makes running his business more cumbersome.
I'm curious if your doctor will entertain such a proposal. A lot of what one gets out of health insurance are the agreed upon rates.

 

[Senator]

Regardless of what Doctor you use, any lab tests can be done in-network, with a prescription. Possibly any prescriptions too, or use a compounding pharmacy.

Then, only the office visits are out of network. Maybe you can pay in cash, and save money too.

 

[ziggy29]

Doesn't hurt to ask. Some docs may accept something closer to a negotiated insurer rate if they are paid up front with no claims hassles. Some won't. And as mentioned above, you can always get tests and lab work (the most costly stuff, usually) done elsewhere in network, and simple office visits are usually not terribly onerous.

 

[youbet]

Is your doc practicing individually or is he in a practice?

 

[Car-Guy]

one which doesn't use that awful mail-order outfit Express Scripts.

+1 except you are far too kind. ES is one of the worst service providers in any industry that I've ever dealt with. They have more rules and traps than the IRS and they all are in their favor.

Doesn't hurt to ask. Some docs may accept something closer to a negotiated insurer rate if they are paid up front with no claims hassles.

Sometimes an out of network doctor will accept the insurance companies out of network rates as full payment. We use a group of doctors that accepts the out of network "reasonable and customary" rates from our insurance company and we pay them nothing, not even a co-pay. In fact, I have often seen them get paid more by my insurance company than an in network doctor for the same services. The doctor gets paid more for being out of network and we pay less. YMMV, depending on your doctor.

 

[MBSC]

Sometimes an out of network doctor will accept the insurance companies out of network rates as full payment. We use a group of doctors that accepts the out of network "reasonable and customary" rates from our insurance company and we pay them nothing, not even a co-pay. In fact, I have often seen them get paid more by my insurance company than an in network doctor for the same services. The doctor gets paid more for being out of network and we pay less.

Those are PPO, POS, or HMO Plus plans. The NY OSCAR plans are EPO. They, along with basic HMO plans, offer no OON coverage except for emergencies.

 

[scrabbler1]

Thanks for the replies.


Bingybear, I have not spoken to the doctor in question yet. The bold part of my post you quoted is speculation on my part, not from anything conclusive.


Many of you mentioned lab tests. I have them done from other providers which are IN-network so I will pay little or nothing for them no matter how the main question in this thread gets resolved. Same for my prescription drugs which are filled by Oscar's in-network pharmacy (CVS), one I have had no problems with.


Only my office visits would be OON, and I would be willing to pay cash for them at the time of service the same way I pay them my copays now.


Youbet, this doctor doesn't seem to be part of a larger network. I make out my copay checks to "XXX Medical Group," where XXX is my doctor's name. His office includes him, another doctor who works with him, his wife who is a doctor in another area, and a Nurse Practitioner (along with the front desk staff). This will probably work in my favor because he won't need permission from others to accept my offer.


Car-Guy, I guess I hadn't had enough bad times dealing with ES to see how lousy they were. We had a thread about them last year (I forget if I began it or not) and I posted my woeful tales of dealing with them. In Oscar's plan, I have the same choices I had with BCBS with regard to how to get my drugs - at a local pharmacy or through ES. The big difference was after the first refill I had to use ES or else BCBS wouldn't PAY for it!


When I visit my doctor next month, I will make sure to ask him this question AFTER he has sent my prescription renewal to the local CVS (he does this with a few point-and-clicks on his laptop as we discuss my medical situation).


One other little wrinkle in going OON is specific to my condition. Sometimes, there are services other than just the basic office visit. Back in May, we had a lengthy discussion about self-treatment training for my Diabetes and that had a separate billing code and a separate charge which Oscar paid an extra $38 (no copay) even though the unadjusted provider charge was much greater. How often would this extra charge occur and how much would I have to pay for it? I don't know.

 

[W2R]

I think it would probably be worthwhile to switch doctors now, so that you are going to an in network doctor in the future. Who knows what the future will bring but you will have an affordable doctor no matter what your needs may become.

Since you are seeing your present doctor next month, you have some time to evaluate and look at the in network doctors. They will know what prescriptions are working for you because you are already taking them.

 

[Beldar]

One other little wrinkle in going OON is specific to my condition. Sometimes, there are services other than just the basic office visit. ... paid an extra $38 (no copay) even though the unadjusted provider charge was much greater. How often would this extra charge occur and how much would I have to pay for it? I don't know.

I am also blessed with the diabetes as well. As far as services outside of a normal office visit, diabetic counseling and education is often provided free from many hospitals and their outpatient clinics. I'm not sure of that is what you are referring to above, but if it is it might be worthwhile to look into what is available to you in your area.

Just one data point.

_B

 

[scrabbler1]

I am also blessed with the diabetes as well. As far as services outside of a normal office visit, diabetic counseling and education is often provided free from many hospitals and their outpatient clinics. I'm not sure of that is what you are referring to above, but if it is it might be worthwhile to look into what is available to you in your area.

Just one data point.

_B

The hospital I was a patient at last year offers an informal monthly support group meeting at no charge. I have attended nearly every session. The hospital is in the process of starting a more formal program which would be covered by insurance although those details are not fully known now. If I were to go OON with my doctor, I suppose I could request that I don't have any of those extended discussions with him or his staff which would incur an extra charge I'd have to pay for in full (or at a reduced rate, if it could be negotiated).

 

[youbet]

I'd have to see him only twice a year and I haven't had any changes to my meds since early January so it's been mostly maintenance work for him.

I think the real issue is embedded in the above.......

If you only see this soon to be out-of-network doc twice a year for routine maintenance work, there is no real issue. At worst case, your negotiations fail and you spend a couple hundred more bux annually. (I know, I know, pennies add up to dollars but if you really prefer this doc and he's good for your health, it would be a small amount to pay.)

The issue I see for both you and doc is the circumstance where you develop some issue related to your diabetes where this out of network doc is involved in your care 5 - 10 (or more) times during the year. I'm not very familiar with diabetes treatment or possible complications, so it's hard for me to speculate. But, if you really feel you'll only see him twice for routine maintenance work, there isn't much to worry about. Negotiate and if that works, great! If it doesn't, so what?

If you believe there is actually some likelihood of needing this doc much more extensively, then either negotiate successfully or switch to a doc that's in your new network.

 

[scrabbler1]

Here is an update on my situation with the doctor in question.


I had an appointment with him today and a few things happened, some unexpected.


First, he didn't know that OSCAR was cutting him out of their network. He was surprised to learn of this from a patient. We went through the 3 options I described in my OP. And, to my pleasant surprise, he was perfectly fine with #3, seeing him OON and paying him the total amount he received from me and OSCAR combined (mostly my copay).


He even told me he was honored that I would consider keeping him as my doctor even if he won't remain in my IC's network. Furthermore, he instructed his staff to investigate how he could remain in the OSCAR network. But at least I know I will remain his patient and he will remain my doctor in 2017. He was very pleased once again with my fine progress and blood test results.


As to the extended discussions I had with his assistant and his staff 6 months ago, he assured me I would not be billed for the amount he received from OSCAR for that, should we have another extended discussion about managing Diabetes.

 

[Just_Steve]

^^Sounds like a Doctor that actually cares.

 

[MooreBonds]

First, he didn't know that OSCAR was cutting him out of their network. He was surprised to learn of this from a patient. We went through the 3 options I described in my OP. And, to my pleasant surprise, he was perfectly fine with #3, seeing him OON and paying him the total amount he received from me and OSCAR combined (mostly my copay).
...
As to the extended discussions I had with his assistant and his staff 6 months ago, he assured me I would not be billed for the amount he received from OSCAR for that, should we have another extended discussion about managing Diabetes.

For your own sanity (and protection), I would compose a simple e-mail or letter to send to the doctor putting this in writing. I could foresee someone in his office easily not knowing this, or perhaps a substitute, or a new person, or perhaps they even change their mind and try to charge you differently.

 

[scrabbler1]

MooreBonds, I agree and will put something together in the next day or two.

 

[scrabbler1]

I did write a letter to my doctor and followed up with him and the insurance company (OSCAR). He did have an application pending although I never saw his name appear in the list of in-network doctors when I checked the OSCAR website every month or so.


But today, with 2 weeks to go until my next appointment with him, I go into the OSCAR website and did a quick search for him, and voila! There he is, back in the OSCAR network. Took a while, but I'm glad he is back in, making things simpler for us and saving me a few bucks, too.