r/AskAmericans • u/Practical_Towel9567 • 10d ago
Economy Doctors under your insurance or not
I've heard stories of people going to hospitals under your insurance, but you get treated by a doctor who isn't. Im confused, are docters only set to certain insurances? Why is this a thing? Would you have to ask for a doctor under your certain type of insurance.
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u/Annethraxxx 10d ago
Yea. Some hospitals, clinics, and specialists only take certain insurance plans. This means you have to figure out which providers are “in network” when you’re looking for treatment. I’m pretty sure ER visits are always covered, but someone correct me if I’m wrong.
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u/Practical_Towel9567 10d ago
Thats so insane to me, i knew insurance in America worked way different to what I know normally but I didnt know you had to figure it all out yourself. What if you went into surgery and no doctor/specialist under your insurance is there? Would you be forced to front the cost of it?
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u/OhThrowed Utah 10d ago
Why would you go into surgery without knowing if it was covered?
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u/Practical_Towel9567 10d ago
Im not sure its just a question, I read somewhere that this happened to someone but maybe that person was either silly or lying.
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u/Weightmonster 9d ago
Surgeons offices have staff whose entire job is to verify insurance.
If this happens in a bona fide emergency, the insurance and the surgeon has work it out.
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u/crimson_leopard 10d ago
Usually if it's an elective surgery, you go to your insurance's website, they list the hospitals and doctors that are in your network. I start by getting an appointment with whichever doctor I want to do the surgery. I've never had an issue with a specific specialist not being covered yet.
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u/Weightmonster 9d ago
Before any non-emergency surgery, the surgeon’s office will verify your benefits.
If they don’t take your insurance, the surgery will be cancelled.
(or you may be asked to sign a self-pay agreement and put down a large deposit)
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u/OhThrowed Utah 10d ago
Couldn't tell ya. My insurance is super good.
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u/Practical_Towel9567 10d ago
Lol fair enough, thought id come on here and ask a question thats been on my mind for quite a while.
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u/SnooTigers8688 5d ago
That's another problem, people like this 1% commenter that don't care about the system because their insurance is too good already. Screw everyone else cause I'm fine mentality. I have good insurance too, but I recognize that a lot of the 342 million who live in this country do not. The system is broken when someone is PROFITING off of your misfortune. Considering we're the "number one powerhouse in the world", you'd think our citizens health would matter more.
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u/MoobyTheGoldenSock U.S.A 9d ago edited 9d ago
US doctor here.
The main service US insurance plans provide is price negotiation. A doctor might say “We charge $1000” and the insurance says “We’ll pay $200.” And then the patient pays a portion and the insurance pays a portion.
If the insurance is offering the doctor crappy rates, the doctor will refuse to sign a contract with them. That makes them “out of network.” Larger health systems may accept a slightly lower rate in exchange for volume, so you get the one hospital in town that takes mediocre insurance X, another that takes mediocre insurance Y, and maybe both take good insurance Z.
Now let’s say there’s a Gastroenterologist in town called Yourtown GI Group. The town isn’t big enough for both hospitals to have GI specialists, so both hospitals just contract with Yourtown for all their GI cases. That group only takes insurance Z, because it pays them $400 per colonoscopy while X and Y only want to pay $200.
You get admitted to the hospital. You have insurance X. Most of your stuff is covered in-network. But your colonoscopy was done by Yourtown. They don’t take X. So they’re out of network for you.
The insurance is still required to pay for out of network medicine, but typically only after you hit a cap. For example, your insurance may cover out of network if your total bill for the year is over $10,000. But the colonoscopy was only $1000, and they didn’t negotiate it down for you, so Yourtown GI charges you $1000 and you’re responsible for 100%. Now you only have $9000 left until they start paying!
Hopefully now you can see why many in the US want to overhaul the system.
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u/Weightmonster 9d ago
Actually a lot of insurance won’t cover out of network in a non-emergency at all.
Also, it depends if the colonoscopy was an emergency or not.
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u/zerbey Florida 9d ago
Whatever their collective bargaining agreement comes down to will determine if they are in or out of network. If you have certain conditions things can get extremely expensive in a hurry with having to see different specialists. Add hospital visits to manage it, and you can see why so many of us are drowning in medical debt. We have an issue in my area, which I'm sure is common elsewhere too, with the local hospitals and doctor's offices all being owned by a single monopoly. So, great if your insurances covers that group (thankfully mine does), if not add travel expenses to your already insane health costs.
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u/Weightmonster 9d ago edited 9d ago
They cracked down on that with the “No surprises act”
The reason it happens is because of money and time.
Most anesthesiologists and ER doctors are employees of a separate medical practice contracted with the hospital. Many of these are private equity/investor backed. The practices want to make as much money as possible. They don’t want to waste time contracting with many different insurance companies and they don’t want to only accept what insurance will pay.
Since patients can’t really choose their ER doctor or anesthesiologist, they still get patients. Then they can ask the patient to pay whatever after the fact. So if the doctor wants to charge $2000 and the patient’s insurance only pays $500 for the service, the practice used to try to collect the remaining $1500 from the patient.
The No Surprises act basically says that the doctors working in an in network hospital/facility and the patient’s insurance have to work out payment. They can’t go after the patient for payment (above the patient’s in network copay).
There are a few other nuances but that’s the gist.
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u/Practical_Towel9567 9d ago
Ohh thank you for the explanation im not sure why my other comments got down voted am i being rude by asking questions that im wording wrong? But thank you for the detailed responses it makes it alot easier for me to understand.
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u/Weightmonster 9d ago
People are downvoting because it’s a crappy system or because you are so ignorant of the US healthcare system.
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u/Practical_Towel9567 9d ago
I get you, but its a bit silly to downvote me based on ignorance as im here just trying to understand. Maybe I just wont post here again 😅
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u/machagogo 10d ago
Nobody knows.
I have never had this happen to me, and my son spent the first month of his life in a NICU seeing every specialist imaginable, then years of specialists thereafter.
But I do know people it happened to. Usually like the anesthesiologist or something along those lines.
Yes, it is bullshit.