How do I know if my doctor is in network?

You go out of your way to ensure that any doctor you see is in your network. You pay your copay before you even see the doctor. Why, then, do you end up receiving bills that you weren’t expecting for services not covered by your insurance? Why doesn’t your doctor inform you that he/she will be performing tests that might not be covered by your policy?

Understanding what your Health Insurance Plan covers

The short answer is that even as an in-network provider, your doctor does not know exactly what your insurance will or won’t cover until the claim has been submitted to your insurance and it has been processed. While it would seem only right that all services provided by an in-network should be covered by your policy, it isn’t as straightforward as that.

Understanding your health coverage policy

In reality, each insurance company has tens if not hundreds of policies that it makes available to individuals as well as businesses. Each one is priced according to the covered benefits. Typically the more services that are covered in a plan, the higher the premium. But even within highly comprehensive policies, there is a growing list of non-covered services. These could be immunizations, tests, and certain procedures that the insurer will not cover as part of the policy. Or the insurer could limit coverage for certain services to particular diagnoses or age of the patient: these services, therefore, could be covered in some instances and denied in others.

Why isn’t my insurance covering anything?

Given the breadth of options for coverage, it is virtually impossible for a doctor to know definitely if a particular service will or won’t be covered under your policy. Insurance companies will not provide that information to a doctor in advance of providing the service and submitting the claim. However, they will supply that information to the member in advance of receiving these services.

What are procedure codes and diagnosis codes?

It is in your best interest to ask your doctor, in advance of care, what procedure and diagnosis codes he/she will be billing for services provided to you. Contact your insurance company and explain which doctor will provide the services and ask them to review the codes against your policy benefits to let you know what, if anything, you will be your financially responsible to pay. They will be able to determine not only which codes won’t be covered, but also, what codes that are covered might be subject to a deductible, requiring a payment from you.

Patients are ultimately responsible to know and understand the benefits of your health insurance.



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