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This is giving me a headache. My wife is getting set up with a new policy at her work and there are 3 different plans, all within 300 to 1000 deductible and 2300 to 3000 OOP max. 2 are PPO's but the basic is an EPO. Because of low weekly deductions from her check and not much more for an out of pocket max/deductible she is considering the basic plan since she is healthy. The only difference in the plans is that the basic one does not cover out of network on anything except emergency room services, transportation and urgent care.
I have been on the phone with the insurance company and I have been transferred 7 times because NOBODY can explain what "in network" is. They need her insurance group number which of course she doesn't have because she wants to know whether her plan would cover any of the local hospitals and Doctors before signing up.
Perhaps I'm over thinking this but I just don't want her signing up for something that won't cover anything if the unfortunate happens. I know she could just sign up for the next grade up plan but that is a considerable increase in her weekly deductions.
In Network is a network of contracted doctors that have agreed on a reduced price for service in exchange for being in an insurance company network
Out of network are doctors that have not contracted with the insurance company
In an EPO plan, you are basically in an HMO, although some insurance companies have national networks vs local/regional ones for an HMO.
If you go out of network in an EPO, non emergency, you pay 100% of the bill with usually no reduction in cost.
In-network, you don't have to pay the difference between the agreed upon cost and the total billed. If you go out of network in a PPO you will have to pay that difference.
It sounds like they are trying to look up the exact network for her plan for you vs just defining what the terms mean.
any company should be able to tell you if an Dr. or facility is in network if you give them the name of the individual or facility. It makes no sense that no one knows. you must have some information regarding the individual plans such as the company the plan is with, and it would be offered through, [her company] In other words, i.e., Aetna, basic plan A-2 through company XYZ, then These are our Dr.s John Smith, Hospital County general etc. Are these in network providers for this plan?
They should be able to work with such info and tell you yes or no.
any company should be able to tell you if an Dr. or facility is in network if you give them the name of the individual or facility. It makes no sense that no one knows. you must have some information regarding the individual plans such as the company the plan is with, and it would be offered through, [her company] In other words, i.e., Aetna, basic plan A-2 through company XYZ, then These are our Dr.s John Smith, Hospital County general etc. Are these in network providers for this plan?
They should be able to work with such info and tell you yes or no.
Not if they don't have the plan information. Individual companies can exclude doctors/facilities from their "network' even under a prescribed network from an insurance company. Some insurance companies have 20+ networks and not all doctors are in each network.
The plan has a list of doctors who are a part of your plan. If you choose to go to a doctor who is not a part of your plan, you will pay more. What's so hard to understand?
In Network is a network of contracted doctors that have agreed on a reduced price for service in exchange for being in an insurance company network
Out of network are doctors that have not contracted with the insurance company
In an EPO plan, you are basically in an HMO, although some insurance companies have national networks vs local/regional ones for an HMO.
If you go out of network in an EPO, non emergency, you pay 100% of the bill with usually no reduction in cost.
In-network, you don't have to pay the difference between the agreed upon cost and the total billed. If you go out of network in a PPO you will have to pay that difference.
It sounds like they are trying to look up the exact network for her plan for you vs just defining what the terms mean.
As above.
The best thing to do is call the doctors and hospitals you would use and find out if they participate with the particular plan you are considering. Do not trust the insurance companies, as their lists of doctors participating in their networks are notoriously inaccurate.
Also, be aware that for hospital services, the hospital may be in network but some doctors may not, including ER doctors and anesthesiologists. You may think you chose a network hospital and then get stuck for non-covered physician charges. Ask the hospital if every physician in the ER, operating room, and pathology and radiology participate with the plan.
Choosing a plan with out-of-network benefits may be safer, even if it costs a bit more and you end up paying a bigger share of the cost if you use it.
Also, if you find that a doctor that you did not actually choose to see, such as in the ER, is out of network, see if you can negotiate down to the in network rate.
In Network is a network of contracted doctors.....
Hospitals, actually.
A doctor is either on-staff.....or not. For example, my mother is on-staff at Sarasota Memorial.
A doctor cannot just walk into any hospital with his/her little black bag and start cutting on people and using the facilities.
Hospital control.....hospital monopolies.....that's what this is all about...no Free Market means everyone gets raped on healthcare costs.
Quote:
Originally Posted by marlinfshr
I have been on the phone with the insurance company and I have been transferred 7 times because NOBODY can explain what "in network" is.
I can explain what it is.
The "Out-of-Network" clause was established and first used in 1939 by the American Hospital Association. When the American Hospital Association created the very first health insurance company in 1946 -- The Blue Cross --- the "Out-of-Network" clause was maintained for the same reason it was created...
....to punish and penalize anyone who dared use a medical facility that was not a member of the American Hospital Association.
Primarily, it was an attempt to run the AMA and hospitals that refused to submit to the dictatorial control of the American Hospital Association out of business.
Granted, the American Hospital Association/Blue Cross eventually took over the AMA's Blue Shield, but it should be understood that the AMA today, is nothing like the AMA 80 years ago....the AMA was co-opted, corrupted and destroyed.
Sort of like the ACLU...noble...righteous...just...when it was first created, and then it was co-opted, corrupted and destroyed.
It's still in use today for the same reason, to punish anyone who does not use the Blue Cross network of monopoly hospitals. You can look here to see how the American Hospital Association owns you...and damn near all Americans.
HEAVY HITTER The American Hospital Association represents 37,000 individual members at more than 5,000 hospitals and health care systems. With one-third of the nation’s hospitals in the red, the association’s primary focus is lobbying against any reductions in Medicare payments. Read more...
View totals for other cycles:
CONTRIBUTIONS
$2,383,767 ranks 137 of 20,981
LOBBYING
$19,251,200 (2012)
$20,823,341 (2011) ranks 5 of 4,368 in 2012
OUTSIDE SPENDING
$1,912,675 ranks 47 of 296
The American Hospital Association gave....
$779 Million to Obama for America 2008
$260 Million to DNC 2008
$428 Million to RNC 2008
Reversing a 60-year tradition of nonprofit health service, the national Blue Cross and Blue Shield Association said yesterday that it would allow its member plans to become for-profit companies that could sell stock to the public.
That's hysterical....a non-profit monopoly. What will they think of next? A for-profit-non-profit?
You don't have Free Market healthcare, and that's why you pay through the nose and your eyeballs are bleeding.
You don't have In-Network/Out-of-Network roofing contractors for homeowner's insurance.
You don't have In-Network/Out-of-Network auto repair for auto insurance.
Aren't you so glad Obamacare reformed the healthcare system to eliminate anti-competitive monopolistic practices like "Out-of-Network"?
Networking...
Merica---a lot of doctors are NOT employees of hospitals. They are self-employed with hospital privileges and work at one or more hospitals. The insurance companies most certainly DO contract with doctors individually, but they also contract with clinics and hospitals to cover their actual staff--sometimes they are MD's other times they provide other services like physical therapy, OT, audiology, etc. Ask your Mom how it works.
Out of network isn't "punishing" people for not using the "right" hospital. It's about controlling costs for the plan and the members. Maybe if you didn't have such tunnel vision and got out in the world a bit you would understand how the real world works. Once you get out of high school I certainly hope you can do some traveling and maybe get a job so you can experience real life and not just life through radical publications on the internet.
And yes, insurance companies do have preferred auto repair shops, roofing contractors, etc.
All health insurance companies in our state have to be not-for-profit by law. It works and the proof is in the premiums...which are, and have been, the lowest in the nation for year yet we are seen as one of the best states for medical care
Really ACA allows insurers the normal 20% net profits on claims.As to doctors they more and more work for statewide associations as group who does everyhting from pay the doctor; bill patients and insurers; to nurses; to run retirement plan and medical insurance as a group. Many times you see the owners being the same doctors much like say startups tech companies with shares.The employee has retirement plus stocks when he retires as part owner. Its not a public traded corporation most often .Less and less private practice now days. They are so successful they have started building and running hospitals mre and more.
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