Frustrating PCP/insurance issue

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michaeljc70
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Frustrating PCP/insurance issue

Post by michaeljc70 » Mon Jan 13, 2020 3:41 pm

I switched insurance as of 1/1 and my PCP is not in the provider directory. I have an HMO and need to select my PCP. According to the doctor's office, he is in the network. The other two doctors in his office are in the provider directory. According to the large medical group my doctor works for, all doctors are in the network and there are no exceptions. This is a large group that has a couple hundred locations and I imagine thousands of providers.

I have contacted the insurance company several times and have gotten nowhere. They keep saying Dr. "Smith" is not in the network. When I say he is and their directory is incomplete they ignore me rather than directing me to someone that handles issues like this.

My doctors office said to pick the doctor that does show up in the directory and it will be fine, but I am not sure since it is an HMO. I am wondering if anyone has experience with this type of thing.

Dottie57
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Re: Frustrating PCP/insurance issue

Post by Dottie57 » Mon Jan 13, 2020 3:57 pm

Perhaps the doctor has not signed the contract papers for the network in question. I would believe the HMO on this over the info from the Dr’s practice.

brainstem
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Re: Frustrating PCP/insurance issue

Post by brainstem » Mon Jan 13, 2020 3:59 pm

would work through the MD office - it is his business to get paid!

SeekingAPlan
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Re: Frustrating PCP/insurance issue

Post by SeekingAPlan » Mon Jan 13, 2020 5:24 pm

I switched to a Blue Cross ACA HMO as of 1/1 as well and cannot select any PCP.

First they tell me my doc is not in network (he is).

Then they say he is not accepting new patients (he is not but will accept existing patients like me).

And, finally, they tell me that I cannot select any PCP until mid-February but all labs, procedures & specialist appointments require approval by the PCP that I cannot select. Seems like a ripoff since I am paying the very expensive premiums but if I go ahead with what was referred & scheduled while under my Cobra PPO it will not be covered because there is no HMO referral in the system and no way my doc can put one in at this time.

Jack FFR1846
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Re: Frustrating PCP/insurance issue

Post by Jack FFR1846 » Mon Jan 13, 2020 5:35 pm

You could be worse off. We called Cigna while on their website. The first 4 doctors on their list that we called while the Cigna CSR was on the phone were unable to take us because they were no longer in the area, had retired or were dead.
Bogle: Smart Beta is stupid

quantAndHold
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Re: Frustrating PCP/insurance issue

Post by quantAndHold » Mon Jan 13, 2020 5:38 pm

My experience with a similar issue in the past (my doc not listed as in network, but the rest of the office is) is that when I got EOBs, some other doctor's name would be on the EOB as the provider. Since everything was getting paid like clockwork, I never worried about it.

This was with a PPO, so I wasn't assigned a primary that was acting as a gatekeeper to all other services. That might make a difference to you. You might have to select one of the other doctors, but then make your appointments with your regular doc until it all gets sorted out.

quantAndHold
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Re: Frustrating PCP/insurance issue

Post by quantAndHold » Mon Jan 13, 2020 5:45 pm

Jack FFR1846 wrote:
Mon Jan 13, 2020 5:35 pm
You could be worse off. We called Cigna while on their website. The first 4 doctors on their list that we called while the Cigna CSR was on the phone were unable to take us because they were no longer in the area, had retired or were dead.
Lest anyone think this stuff is new, 30 years ago, my company switched plans to a HMO. One of my coworkers was pregnant. The only OB/GYN in the network was over 50 miles away. We live in a city with a population of 3 million, so it isn't like there aren't OB/GYN's on every corner. The company signed her up for an individual Kaiser plan, so that she would have reasonable coverage. The rest of us.... I'm just glad I was young and healthy at the time.

I tried to sign up for an individual Dental plan last fall. One of those $7/month plans on one of the exchanges. The nearest dentist on the plan was in...Mexico.

SeekingAPlan
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Re: Frustrating PCP/insurance issue

Post by SeekingAPlan » Mon Jan 13, 2020 5:57 pm

quantAndHold wrote:
Mon Jan 13, 2020 5:45 pm
Jack FFR1846 wrote:
Mon Jan 13, 2020 5:35 pm
You could be worse off. We called Cigna while on their website. The first 4 doctors on their list that we called while the Cigna CSR was on the phone were unable to take us because they were no longer in the area, had retired or were dead.
Lest anyone think this stuff is new, 30 years ago, my company switched plans to a HMO. One of my coworkers was pregnant. The only OB/GYN in the network was over 50 miles away. We live in a city with a population of 3 million, so it isn't like there aren't OB/GYN's on every corner. The company signed her up for an individual Kaiser plan, so that she would have reasonable coverage. The rest of us.... I'm just glad I was young and healthy at the time.

I tried to sign up for an individual Dental plan last fall. One of those $7/month plans on one of the exchanges. The nearest dentist on the plan was in...Mexico.
LOL! I passed on the dental because they were HMOs too and no dentist I wish to see was a participant.

Having a medical HMO is new to me. In times past when I did not have employer coverage I was able to purchase PPO coverage. That was not the case this time around with ACA. It was all HMO's and one very narrow network PPO that my local hospitals and doctors did not accept.

Topic Author
michaeljc70
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Re: Frustrating PCP/insurance issue

Post by michaeljc70 » Mon Jan 13, 2020 6:06 pm

Jack FFR1846 wrote:
Mon Jan 13, 2020 5:35 pm
You could be worse off. We called Cigna while on their website. The first 4 doctors on their list that we called while the Cigna CSR was on the phone were unable to take us because they were no longer in the area, had retired or were dead.
This is a subsidy of Cigna.

nydoc
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Re: Frustrating PCP/insurance issue

Post by nydoc » Mon Jan 13, 2020 7:34 pm

This is not Drs interest to find it out for you. Reimbursement is so low these days that this headache is not worth for most practices. You bought the insurance you have to figure it out with your insurance company.

Topic Author
michaeljc70
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Re: Frustrating PCP/insurance issue

Post by michaeljc70 » Mon Jan 13, 2020 10:25 pm

nydoc wrote:
Mon Jan 13, 2020 7:34 pm
This is not Drs interest to find it out for you. Reimbursement is so low these days that this headache is not worth for most practices. You bought the insurance you have to figure it out with your insurance company.
1) I'm not sure why they would agree to a contract with such low reimbursements. My doctor is in group of hundreds and I have to believe paid on salary. What the corporation is reimbursed should have little bearing on it. I think the days of small practices in urban environments is mostly a thing of the past.
2) I thought being in the directory was a plus- marketing for new patients.
3) I had no hand in contract negotiating between my doctor's company and my insurance company.

Frankly, I will just go to someone else if this is not easily resolved. Generally, it is a hassle to switch doctors with records, locations, etc. But if I can go to another doctor in the same office with no hassle.....

toofache32
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Re: Frustrating PCP/insurance issue

Post by toofache32 » Mon Jan 13, 2020 11:20 pm

michaeljc70 wrote:
Mon Jan 13, 2020 10:25 pm
nydoc wrote:
Mon Jan 13, 2020 7:34 pm
This is not Drs interest to find it out for you. Reimbursement is so low these days that this headache is not worth for most practices. You bought the insurance you have to figure it out with your insurance company.
1) I'm not sure why they would agree to a contract with such low reimbursements. My doctor is in group of hundreds and I have to believe paid on salary. What the corporation is reimbursed should have little bearing on it. I think the days of small practices in urban environments is mostly a thing of the past.
2) I thought being in the directory was a plus- marketing for new patients.
3) I had no hand in contract negotiating between my doctor's company and my insurance company.

Frankly, I will just go to someone else if this is not easily resolved. Generally, it is a hassle to switch doctors with records, locations, etc. But if I can go to another doctor in the same office with no hassle.....
Nydoc is correct. The public doesn't understand how when you sign up for one of these plans, you are one of thousands of patients and have lost all your leverage with the doctor's office. There is no reason for the doctor to spend unreimbursed time on a this when they have an office full of patients who have the same coverage (same pay) without issue.

Direct Primary Care might be what you're looking for.

Topic Author
michaeljc70
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Joined: Thu Oct 15, 2015 3:53 pm

Re: Frustrating PCP/insurance issue

Post by michaeljc70 » Mon Jan 13, 2020 11:54 pm

toofache32 wrote:
Mon Jan 13, 2020 11:20 pm
michaeljc70 wrote:
Mon Jan 13, 2020 10:25 pm
nydoc wrote:
Mon Jan 13, 2020 7:34 pm
This is not Drs interest to find it out for you. Reimbursement is so low these days that this headache is not worth for most practices. You bought the insurance you have to figure it out with your insurance company.
1) I'm not sure why they would agree to a contract with such low reimbursements. My doctor is in group of hundreds and I have to believe paid on salary. What the corporation is reimbursed should have little bearing on it. I think the days of small practices in urban environments is mostly a thing of the past.
2) I thought being in the directory was a plus- marketing for new patients.
3) I had no hand in contract negotiating between my doctor's company and my insurance company.

Frankly, I will just go to someone else if this is not easily resolved. Generally, it is a hassle to switch doctors with records, locations, etc. But if I can go to another doctor in the same office with no hassle.....
Nydoc is correct. The public doesn't understand how when you sign up for one of these plans, you are one of thousands of patients and have lost all your leverage with the doctor's office. There is no reason for the doctor to spend unreimbursed time on a this when they have an office full of patients who have the same coverage (same pay) without issue.

Direct Primary Care might be what you're looking for.
But they don't! I am often the only one in the waiting room. I get in with little to no notice. I barely wait minutes beyond my scheduled time to see the doctor. You guys made a lot of assumptions.

BTW...the doctor himself is spending NO time on this. The large company he works for has people that handle these things. That is why doctors join these larger groups- so they can handle the bureaucracy. They negotiate contracts and should be on top of it.

nydoc
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Re: Frustrating PCP/insurance issue

Post by nydoc » Tue Jan 14, 2020 7:42 am

Drs these days feel like battle defeated. Nothing excites us anymore. We came to treat patients and ended up dealing with paperwork , insurance authorization, denials, regulatory burdens all day. Even if your matter involves just sending an email to corporate office, the physician will have zero interest in doing this. There is a reason that physician is now on salary.

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