Tag: health insurance

Is your doctor leaving your health plan network?

Is your doctor leaving your health plan network?

What can you do?

The prevalence of doctors, providers and even larger healthcare groups leaving Health Maintenance Organization (HMO) and health plan networks appears to be on the rise.  While we can appreciate or even sympathize with a doctor’s need to make a change, patients are ultimately burdened with having to pick up the pieces to ensure they have continuity of care, especially if they’re in the middle of being treated for a condition.

Providers leave a health plan network for any number of reasons:

  • Retirement
  • A change in the group’s practice
  • Changing professions
  • Administrative stress that comes with participating in a health plan network
  • Compensation

A provider’s network contract typically gets renewed periodically. One of the most significant reasons doctors will leave networks (or at least threaten to leave) is being unable to negotiate or come to terms on the financial reimbursement of services.  The cost of doing business goes up for every business at one point or another, so who could blame a doctor for wanting to get paid more.  While money is important, sometimes the administrative duties to participate in a network can be too burdensome to manage.

The Financial Impact is Real

If you continue to seek treatment from a doctor who no longer participates in your plan’s provider network, the likelihood is high you’ll end up paying the full charge billed to you, not the lower health plan rate.  If your plan does cover out-of-network expenses, the service will be applied to your out-of-network deductible. While you would get credit applied to the deductible, you probably will need to pay the full charge billed until your deductible is met.  According to Kaiser Family Foundation research, the average In-network deductible for an employer plan is $2,000 for single coverage and $4,000 for family coverage. Out-of-Network deductibles are usually double that of In-Network deductibles.

When a doctor is not participating in a health plan’s network, they are free to charge their normal private rate / street-price.  A $75 In-Network office visit rate would become a $150 or higher rate that you would be responsible for paying now that the doctor is out-of-network.    

When a medical claim is applied to the Out-of-Network deductible, the health plan will still apply only what they think is a reasonable charge for the office visit, and potentially not the full billed charge if higher than their rate. You would only receive deductible credit for what the health plan set as the reasonable rate. 

Higher Reimbursement Rates Could Mean Higher Insurance Premiums

One strategy health care provider’s use to put pressure on employers is to send letters to their patients stating that they plan to leave the health plan’s network because the health plan will not pay for higher rates of reimbursement.  This may come across as a one-sided viewpoint.  Negotiations between health plans and providers occur all the time, especially during contract renewal periods. Such tactics seem to be a way for employees to put pressure on their employers who in turn contact their health plan.

Geographically, one large provider group leaving a network could mean a significant disruption in network coverage.  Health plans want to avoid such gaps in network membership as it doesn’t bode well for their renewal prospects.  Employers will most certainly hear noise from employees who consider traveling a longer distance to find affordable health care. 

If a health plan capitulates to paying higher rates, it could set off a series of unintended financial consequences:    

  • First, other health care providers may get wind of such negotiations and will expect higher rates of reimbursement.
  • Second, higher reimbursement rates could have an impact on the annual premiums come renewal time. While a health plan could try to absorb the higher reimbursement rates overall, eventually it will catch up and bleed into the costs they pass on to employers. Employers don’t like higher premiums as that means their costs go up. The downstream impact will be to pass on the premium increases to employees through employee payroll contributions. Employers could also compensate for higher premiums by changing the plan design like raising deductible levels or reducing the coinsurance rates from say 90% to 80% for In-Network services which still passes on more of the cost to employees.

Individuals who get their health insurance through Marketplace plans (ACA plans) have no real leverage to influence premiums. The only option is to consider changing plans during the next annual open enrollment period to a health plan where your provider of choice is considered In-Network. This change may end up with the person paying higher premiums. In the end, patients end up being the beneficiaries of healthcare inflation which is a real and immediate burden.

What are your options if your doctor is leaving the health plan network?

Typically, the health plan will mail a letter to all impacted members within 90 days of the doctor leaving the network. This assumes the doctor informed the health plan of their departure. You may also receive a letter from the doctor informing you about the change in health plan network status. Most negotiations end in an agreement avoiding departure from the health plan network, or there’s an extension to the contract to continue negotiations in good faith, thereby postponing any impact on patients. Nevertheless, patients are left in limbo wondering what will happen.

In anticipation, you can look for another In-Network provider. This can be a cumbersome, time-consuming process, you’ll need to search the health plan system for a list of In-Network providers and then contact each one to see if they are accepting new members. New patient appointments may take longer than expected so it’s ideal to jump on this as soon as possible.

You may incur a cost to have your medical records transferred to your new provider. These costs are not covered by your health plan.

What if you are currently receiving treatment and prefer to remain with the same provider, or perhaps you live in an area with limited options for a particular specialty? Changing “provider teams” mid-stream can be stressful, and cause delays or even changes in your course of treatment. Often, a provider who leaves a health plan may be part of a larger group of physicians and health care professionals who are leaving the same health plan network. This can impact a wide range of services and treatment you are receiving beyond the office visits to one specialist. You may also need lab work, medical injections, radiology, physical therapy, mental health and other services that have been delivered by those providers within the same group that is leaving the network.

Continuity of Care Option

Your health plan may offer a special process called Continuity of Care, whereby the health plan will make an exception to continue covering all of your treatment by the providers who are leaving the network while you make time to find another In-Network provider. The approval may cover claims for an additional 90 days as In-Network claims.

While on the surface this sounds great, and your out-of-pocket costs may be lowered for the interim period which is a plus, check with your doctor to see if they will continue to treat you and accept the negotiated rate; the provider may expect you to pay full charge regardless.

You always have the choice to continue with the provider on an out-of-network basis assuming they are not retiring. Nevertheless, financial costs weigh heavily on our decisions. Today, medical debt ranks as the top reason for bankruptcies even for people with health insurance.

If your provider leaves the health plan network, there really doesn’t seem to be too many options available other than finding a new provider if you want to avoid higher costs. You can find a new doctor who is In-Network, you can try to change your plan where your doctor does participate, or request a continuity of care option which is not a long-term solution.

Edited by Sebastian Pokluda

18% of Health Plan Claims Get Denied: What action can you take to remedy?

18% of Health Plan Claims Get Denied: What action can you take to remedy?

I believe it’s fair to say people take their health insurance for granted.  They expect health insurance to be there when they really need it. Nonetheless, a misalignment exists between people’s expectations of what health insurance should do and what it actually does. This point is most apparent when a claim is denied by your health insurance company.

The Kaiser Family Foundation analyzes the transparency data released by the Centers for Medicare and Medicaid Services (CMS) on claims denials and appeals for ACA Marketplace plans annually where over 140 health plans provide health insurance coverage for about 17 million people in the United States.

On average 18% of medical claims submitted to these health insurance plans  are denied.

Based upon our expectations, denials shouldn’t happen, but they do.  A glimpse at the different denial categories sheds light on the misalignment between the health care and health insurance industries raising the question WHY?

Let’s take a look at the major buckets for the denial reasons and try to shed some light on what might be happening, and whether you can do anything to avoid or fix if you have a denied claim.

Contractual denial – coverage excluded for a specific service 16%

The service performed just isn’t covered or included in the plan.

Prior authorization or referral not obtained. 10%

You or your doctor did not obtain (or did not complete the process) for prior approval from the health insurance carrier.

Claim or service was not medically necessary – 2%

Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms did not meet accepted standards of medicine. This is still kind of vague, but is the guiding principle.  Here’s a deeper definition from BCBS of Massachusetts.

Experimental or investigational – <0.1%

The use of a service that is not recognized by the Plan as standard medical care for the condition, disease, illness or injury being treated.

Eligibility or rescinded health plan – <0.1%

The patient was not actively enrolled in the health plan for the date(s) of service.

Other Reasons – 59%

While this category appears to be a catch-all, it does include incorrect claim submissions, adjudication or administrative errors. This category interests me the most. While health insurance is technology intensive, it still relies upon manual intervention. People still need to complete a form or performing a task on a timely basis. Additionally, the technology that connect or holds processes together from different vendors or suppliers still needs to work properly. If one of those connections breaks, the downstream impact can be significant.

Most Claims are Not Appealed

In their analysis of the claims transparency data, Kaiser Foundation discovered how the vast majority of people do not appeal their denied claims. Approximately 1/10th of 1% of all claim denials were appealed. Surprisingly, in 2020 37% of ACA plan appeals were overturned.  That’s nearly 2 out of 5 which are pretty are good odds. I would venture to guess that if your claim was denied for an administrative error, nearly 100% of those claims would be overturned by appeal assuming they were eligible services to begin with.

It is unfortunate claims are denied and that we as covered members have to pursue and take action to reverse errors or gaps in care. All we want to do is get treated by our doctor and to have our health insurance help finance that service. We end up having to navigate a healthcare and health insurance system which are not always setup for success.  There are many hidden barriers, roadblocks, and snafus which are out of our control.


If you get your health insurance through an employer or group plan, not through the Open Market plans, I wouldn’t necessarily think you’re out of the woods; your plan could be denying the same percentage of claims.    Let me point out some information to support why we should take pause and believe that the high denial rate is prevalent in all types of health plans:

  • Healthcare providers, doctors who are In-network are the same providers for the most part who participate in the networks offered to employer plans.  Same doctors.
  • Type or kind of healthcare treatment received by people enrolled in these affordable care act plans through healthcare.gov are the same kinds of treatment people get who are covered by employer plan (and probably Medicare).
  • The process to submit medical claims to insurance companies is the same as that for employer plans.
  • The people who work at these insurance companies are the same.
  • The computer systems, logistics, internal networks, pharmacy systems are the same.
  • We’re all using the same healthcare and health insurance system.


Employer health plans are not required by law to report on their claims activity. One could only project that the same percentage and types of denials are occurring with claims that come from employer group or union plans.   It’s the same insurance companies who administer.

In 2021, the number of people covered by health insurance from their employer sits at around 156 million, or 49% of the country’s population.  This is according to research done by Kaiser Family Foundation. That’s a lot of people. This means a lot of claims are flowing through the insurance companies systems.  18% of claims, if accurate for employer plans, is a lot more claims and a lot more healthcare costs being passed on or paid for by the very same people the health insurance is supposed to health in their financing.

What actions can you take to avoid or handle your denied claims?

  1. Ask up front whether the treatment your doctor is about to provide or recommends is covered by your health plan. 
  2. If referred to a specialist for a special procedure ask up front if you need a referral.
  3. Retain and provide your latest health plan ID Card to your healthcare provider at the time of service.
  4. Verify timely that the claim was processed/paid by the insurance plan as expected
  5. Read the Explanation of Benefits statement (EOB) online before you make any payments to your doctor. 
  6. Engage your In-Network provider to go to bat for you.
  7. File an appeal. It’s the official way to put the insurance carrier on noticed and they have to respond.  
  8. If you get health insurance through your employer, ask your HR or Benefits contact for assistance. Can they get someone at the insurance company (account rep) to help intervene.
  9. After you’ve exhausted other measures timely, you can contact your local state insurance department, they may have an ombudsmen or insurance complaint department who investigates. They will at the very least send a letter to the insurance company requesting details on your situation.  Insurance companies are accountable to these entities at least in providing visibility and getting an accurate assessment.

In summary:

  • Pay attention to your claims on a timely basis
  • Use the insurance website to track your claims
  • Ask up front if your treatment is covered
  • Don’t assume what you’re billed by the doctor is accurate or what you owe
  • Keep notes

To learn more about how to improve your health insurance literacy, listen to the Maximize Your Health Insurance Podcast series which is based upon the book Maximize Your Health Insurance authored by William J. Pokluda available on Amazon.com.  

Health Insurance Literacy workshops offered in Connecticut: October 2022

Health Insurance Literacy workshops offered in Connecticut: October 2022

Want to increase your knowledge about health insurance literacy?

Join a live, in-person session to learn about foundational health insurance literacy skills that can help you gain control, make more informed decisions and potentially save money.

Register for one of three sessions offered in October in the Fairfield County, CT area through a local continuing education program. Click the link below to access and register for the course.

Trumbull, CT. October 11. 6:30 – 8:00 pm Search the school website for Health Insurance in the Fall/Spring Courses tab.

Greenwich, CT. October 19. 6:30 – 8:00 pm Click here to access the school website. Search for the course in their catalog for Health Insurance.

Ridgefield, CT. October 26. 6:30 – 8:00 pm Click here to access the school website. Search for the course in their catalog for Health Insurance.

Focused primarily for people who get their health insurance through an employer or Healthcare.gov / open market, the course will review how the health insurance industry works, identify best practices you can put into action right away and cover top five HIL skill sets:

  • Health insurance terms & concepts
  • How to understand what your plan covers
  • How to choose a health plan
  • Navigate tools and resources
  • Managing your claims questions

This course is taught by William Pokluda, a certified benefits professional (CEBS) with over 30 years of experience managing corporate benefits and working in the insurance industry. William has proven/demonstrated experience working with employees and their families helping them learn about and get the most from their health insurance. He is the author of the book “Maximize Your Health Insurance, Keep more money in your pocket”.

*A copy of the book Maximize Your Health Insurance will be available for purchase at a discount or offered on a complimentary basis. Depends on the particular program. The book can be purchased on Amazon for $9.99.

Surprise Medical Billing – What You Need to Know

Surprise Medical Billing – What You Need to Know

How would you feel if you received a bill related to a recent emergency room visit, but you don’t recall who the physician was? And that the amount due on the bill was an astronomical dollar amount which your insurance plan isn’t covering? Academic researchers have found that millions of Americans receive these types of surprise bills each year, with as many as one in five emergency room visits resulting in such a charge.

The U.S. government and more than a dozen states have passed laws to help protect people against surprise medical billing. While insurance companies and physicians should work together when such bills arise, you need to know what to expect if such a thing happens.

First, let’s clarify surprise medical billing.
Surprise bills happen when an out-of-network provider is unexpectedly involved in a patient’s care. Patients go to an In-Network hospital or emergency room facility and receive services from a physician, anesthesiologist or specialist who is not in the insurance plan network. Essentially, you don’t have any control over who is involved in your case.

Physicians are not always employees of a hospital. The hospital itself may be a free-standing building considered In-Network by your insurance plan. The actual treatment you receive may be delivered and billed by individual physicians and specialists who work at the hospital, but are not actual employees of the hospital, and are potentially considered out-of-network.

Federal and state laws have been passed to ensure that insurance companies cover such surprise bills from out-of-network providers, that prior authorization is not required, that insurance companies pay those providers a fair price. In the end, you would not owe any more than you would if those providers were all in-network, which includes costs related to copayments, coinsurance and deductibles.

Visit the Health and Human Services website to read more about protections from surprise medical billing.

All of us may get surprised when we receive a bill from a health care provider. We expect our health insurance to cover things, but it can be fuzzy as to what we truly owe. You must continue to view your insurance plan’s explanation of benefits (EOB) statement once they process the claim to determine what you owe. If you believe you’ve been wrongly billed, contact your insurance plan.

When does the Surprise Medical Billing provision no longer apply?

Once you are discharged from the hospital, emergency room or ambulatory care facility, you are back to being a regular citizen responsible for choosing your own providers. Often, patients receive discharge orders that require them to schedule follow up visits with a surgeon or a specialist. While you can continue to see the same provider who treated you in the emergency room or hospital, it’s your responsibility to know if that provider is In-Network. If you continue to receive treatment from out-of-network physicians after you are discharged, the surprise medical billing provisions no longer apply.

Your employer or medical plan is required to provide a model notice or a written explanation of the requirements of surprise medical billing laws. These notices must be made public, such as on a public website of the plan or insurer. Contact your employer or insurer to read your plan’s specific notice.