Health Insurance Claim Articles

Don’t Blindly Trust Your Health Insurer’s In-Network Medical Provider List

By Jeffrey L. Greyber, Esq.

Most health insurance companies make their in-network medical providers list available to policyholders, oftentimes via the carrier’s website or a printed directory. And most health insurance policies place the burden (or at least the initial burden) of locating in-network medical providers squarely on the shoulders of the policyholder. Well, actually, this should not be too much of a “burden” equipped with the carrier’s medical provider list, right? Hum, not so fast…

All too often, clients (or potential clients) come to me puzzled by the fact that the in-network medical providers listed by their health insurance carrier for a particular kind of care are not the right fit. Sometimes, the in-network medical providers listed by the insurance company are, in reality, not trained for the particular type of care they are being listed for. For example, I recently encountered an insurance company who had a plastic surgeon specializing in breast augmentations listed as a neurologist capable of performing intricate back surgery. Sometimes, the in-network medical providers listed by the insurance company are no longer practicing or are now practicing solely in an environment (e.g., hospital only) that will not suit your particular needs. Sometimes, the contact information for the in-network medical providers has changed and not been updated. Sometimes, the in-network medical provider listed by the insurance company is no longer networked with the carrier.

The list of potential inaccuracies associated with the in-network medical provider lists published by insurance companies can go on and on, but there is one moral to this story – do not blindly trust your health insurance company’s in-network medical provider list. If you are shopping for insurance and know that you require a particular kind of medical provider, research your potential carrier’s medical provider list to confirm that the in-network list does, in fact, include medical providers capable of providing you with the care you will need. If you are already insured and on the cusp of obtaining medical treatment, make sure you confirm the propriety of an in-network medical provider before wasting your time visiting someone who is not qualified to properly care for you. If you research the in-network medical providers listed for a particular kind of treatment and none are appropriate for what you need, most health insurance policies obligate the carrier to approve an out-of-network provider. But do not assume as much. Before you treat with an out-of-network provider because your carrier’s in-network medical provider list does not have someone suited to care for your particular needs, make sure to communicate (preferably in writing) with the carrier regarding same and get the carrier’s approval of same in writing.

Health Insurance Claim Articles