Difficulty determining a physician's network status
February 22, 2015
Whether a physician is considered in-network or out-of-network by a patient's insurance plan can have large financial implications. Unfortunately, ascertaining that status can be difficult. Kaiser Health News ran an interesting article exploring one couple's difficulties in this area. In this particular case, a doctor was part of two different medical groups and could bill under each one. The doctor billed under one medical group that was not in-network, resulting in out-of-network charges for the couple, despite the insurance company's own website assurance that the doctor was in-network. It was a bizarre case of the doctor's staff having more influence on the final charges than the actual patient.
Insurance network coverage can be tricky and in our own investigation, we have found plenty of incorrect insurance information. While not a perfect solution, one step that would help immensely would be for insurance companies to release network information in a industry-specified format that could be understood by computers. Tools could be built on top of those data feeds to help physicians catch errors and to help patients make better decisions.