What to Do If Your Doctor Bails on Your Health Plan
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Whether you finally found a physician with great bedside manner who your kids trust (or at least tolerate) or you see a top-notch specialist for a serious health issue, it can be a heart-sinking moment when your doctor's office informs you that they’ll no longer be participating in your health insurance plan.
“Networks are becoming narrower each year as part of cost containment,” says Bruce Elliott, manager of compensation and benefits at the Society for Human Resource Management. “In addition, we are seeing physicians leave insurance networks to strike out on their own.”
Staying with the doctor you love can mean a separate (and higher) deductible, steeper co-pays or co-insurance, and a higher out-of-pocket maximum—and that assumes your plan allows you to go out of network. If you're in an HMO that doesn't have a POS (point of service) option, visits to your out-of-network doctor might not be covered at all.
What's more, you could lose out on free preventive care. Even though the Affordable Care Act, aka Obamacare, mandated that routine physicals and certain screening tests be 100% free, that rule applies only if you stay in network.
Elliott and other experts say you have a few options if your top doc pulls up stakes. Take a deep breath and make the following moves.
If you want to stay with your doctor...
Ask for a break if you’re picking up the tab. “If your current doctor is someone that you absolutely can't do without, talk to that doctor directly about your situation and ask if they would consider providing you a discount if you paid out of pocket,” says Ian Siegel, CEO and co-founder of recruiting and benefits technology company ZipRecruiter.
Pay with pre-tax dollars. “Calculate how much you’ve spent at your doctor’s office over the last year and set up a flexible spending account to cover the out-of-network fees for the next year,” Elliott advises. Even though you'll be paying out of pocket, you'll be able to pay the first $2,550 with pre-tax dollars if you set up an FSA ($2,550 is the annual maximum you're allowed to contribute for 2015; the IRS usually ticks it up according to inflation, so the current low inflation makes it likely that the amount will remain the same for next year.) "You’ll be paying the fees with money that has not been taxed, saving you approximately 20% to 35% depending on your income tax bracket," he says.
Switch health plans. “If the doctor-patient relationship is important to the patient, they should choose a plan that includes that doctor in-network,” says Hector De La Torre, executive director of Transamerica Center for Health Studies. But keep in mind that even though this will cut down on out-of-network paperwork and lower your out-of-pocket costs, this is a big change that is likely to affect your premiums, deductible, and your relationship with any other medical professionals your family visits.
If you decide to switch doctors...
Ask for a referral immediately. If you just can’t afford to switch plans or pay out of network (a likely scenario for many families), ask your current provider for a referral as soon as possible. “If someone knows that their doctor will be leaving a network, sooner is always better than later," Elliott says. "Practices with good reputations fill up quickly, especially in narrow networks." When you contact the new practice, make sure it accepts your insurance.
Make sure both docs are on the same page. “Ask your current provider to communicate with your new provider to help coordinate care during the transition,” says Danielle Hartigan, assistant professor of natural and applied sciences at Bentley University. Continuity of care is important for the best medical outcomes, she says, so it will benefit you to be proactive about coordinating the transfer. “Also, make sure to transfer your medical records," Hartigan says. Since a growing number of practices use electronic records, your new doctor might be able to access your records with just a few clicks.
Check your coverage for the new doc’s affiliations. “Be sure to check not only that the doctor you find is in network for your new plan, but also that the hospital that doctor is affiliated with for any procedures or hospital stays is in network as well,” Siegel advises.