1. How do I know if a doctor is in my network?

It should be fairly simple to determine if a doctor, hospital, or medical provider is in network or not, right? It should be….but it isn’t always that straight forward.

Here’s how the system works. Any one insurance company offers many different health plans. Each plan is attached to its own network of doctors and medical facilities. There isn’t simply one group of providers that is in network for an insurance company. Those networks depend on the actual plans.

2. How Can I Verify if a Provider is in My Coverage Network?

When you visit a doctor, lab, hospital, or other health care facility, you need to confirm two things:

1. Which insurances they accept (i.e., Blue Cross, Medicare, Oxford, Aetna, etc.)
2. Which plans within that insurer they accept

Confirming the second point is most critical. While a provider could accept Blue Cross, for example, they might not participate in the Pathways plan. And if your plan is the Blue Cross Pathways plan, that provider would be out-of-network for you.

3. Why won’t some doctors accept exchange insurance or marketplace insurance?
Additionally, many doctors and facilities do not participate in the plans offered on the State and Federal Exchanges. This means that a doctor could participate with Blue Cross, but not with any of the Blue Cross policies offered on the Exchanges. If you saw that doctor, you would be seeing him/her out-of-network and incurring higher, if not all, fees associated with that visit, depending on your coverage.

You may be asking yourself, “How do I find out if a provider is in network with my insurance plan?”
It’s best to call the insurance company, not the facility. A provider or facility will not know what plan you actually have, so they cannot fully confirm if they participate in that network. The insurance company, being the one that created the networks, can provide the definitive answer to the question. They will know what plan you have purchased, they will have access to the specifics of that plan, and they will be able to tell you if your provider is in that network. Be sure to take down the name of the representative you speak with in case you ever need to reference the call.

Again, if the process becomes overwhelming, seek the assistance of a patient advocate. Making assumptions could lead to medical bill problems and unnecessary medical debt.