Out of Network Physican

[tired_teacher]

(Please feel free to place this in the correct discussion board.)

I hope everyone is doing well. I need some help. I’ve just agreed to take an HMO Humana policy to replace my Medicare card. I am so thankful to have had insurance. I know so many of you do not. It is so sad.

My MS specialist is Dr. Douglas Jeffrey in Moorseville, NC. I am not sure if he is an out-of network physician simply because he isn’t showing up on Humana’s website as an in-network physician. Humana says it could take awhile for his name to appear on their database since he’s relocated to a new office in the past few months.

My scattered brain question I am trying to get to is do any of you know if Dr. Jeffrey takes any of the Humana HMO plans. I’ve called and asked several times, but I’ve always been put on hold. This office staff is busy! They have gotten lots of stuff going on.

I cannot imagine not having Dr. Jeffrey in my MS world!
If worse comes to worse, is there a good MS doctor in the Kingsport, TN area? Roanoke, Va?

I’ve belly-cried over all this stuff.

If I did get to see Dr. Jeffrey and had to pay an out-of pocket fee for an out-of-network physician, then how bad could it get?

Please share some of your stories with me. Please!

xoxoxoxox

[ejonesbowlie]

I use an out of network MS Specialist

Hello!

My MS Specialist (Allan Bowling, Denver) is out of network and I do have to pay out of pocket for my actual office visits. I believe they are $150 a visit. This goes towards my $12,000 yearly deductible..probably not going to meet that However, so far...all of my treatments/meds/therapies and etc. I am able to have billed in network as those entities do accept my insurance.

So depending on how often you actually visit your specialist, it isn't that bad considering it is the one you like/trust. At least that is how I feel

Beth

[onlyairfare]

I feel similarly to ejonesbowlie. To see a doctor that I know and trust is well worth the increased out of pocket cost to me. My cost has also been similar - about $150 for an office visit instead of the $50 co-pay for an in-network specialist.

Here is how my insurances have worked for "out-of-network," though you will have to read the fine print in your own plan to determine how it works for you. And of course I'm using round numbers to make the math easy, while the actual numbers may be different.

The initial listed charge for an office visit might be $500, but the insurance company has negotiated a contract with the doctor's office to pay $300. In-network I have the set co-pay of, say, $50 and the insurance company pays the rest, or $250 ($300 negotiated rate minus the $50 I paid). The out of network coverage requires that I pay a percentage of the "cost," maybe 30%, while they will pay 70% of the bill. This is usually a larger cost to me than it would have been had I stayed in-network.

However, the insurance company will pay their 70% share of only $300 (or $210) - what they would have paid had I seen an in-network doctor. However, I have to pay a bill from the doctor's office for $290 - the original $500 that the doctor charged, less the $210 that my insurer paid. Note that the insurer does NOT pay 70% of the billed ($500) charge.

Some insurances will not pay anything if you use an out of network doctor or hospital. Eeek! Read your plan description carefully so you know what you will be responsible for paying.

I am surprised that Humana can't or won't tell you if Dr. Jeffrey is in their network. I thought there were rules about "transparency" for insurance companies requiring them to tell you whether your doctor is or is not in your network.

I don't know any specifics but if you are thinking about docs in the Tri-Cities area (Kingsport-Bristol-Johnson City), I think you will find MS specialists at the medical school in Johnson City (ETSU) or one of their affiliated hospitals.

[ejonesbowlie]

Yes, my out of network coverage is terrible. I have to meet the $12,000 deductible first (which for just dr.' s visits is never going to happen) and then they pay only 50% once the deductible is met. My in network is similar to what you describe..the negotiated rates and they pay a percentage and etc. Gotta love insurance companies!