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In-Network or Out-of-Network Physician: What’s Best For You?

Few patients truly grasp what it means when your primary care physician contracts into an insurance network. Actually, until doctors (including me!) have been under contract for a few years, we’re sort of confused about it ourselves. And it doesn’t help that in-network contracts vary widely among health insurance companies.

Basically, the in-network doctor has agreed to accept a fee schedule very much discounted from what she would normally charge. She’s doing this so she can have access to the large number of patients enrolled in that particular health insurance company network. The contract she signs is completely non-negotiable, as ironclad as the one you signed when you agreed to 18% interest on your VISA card. Also, the insurer has the right to change the rules or lower reimbursement rates on a whim, a right, by the way, that’s spelled out in the contract.

Some doctors have likened their network contracts to slavery, but that’s just silly. Physicians have martinis after work, join country clubs, take nice vacations, and eat in expensive restaurants. But being beholden to a network invariably discourages independent thinking. There are network rules and you’re expected to follow them. When you receive a notification of a rule change, you’d better be familiar with it or suffer the financial penalties.

At WholeHealth Chicago, we receive endless bulletins on what’s covered and what’s not. In the past year, we were instructed never, ever to test patients for food sensitivities. More recently, we were directed to discontinue saliva testing for sex hormones and adrenal gland function and to stop testing for inflammation (hsCRP) and vitamin D levels. If a patient needed individually compounded bioidentical hormones, it was on her dime. The hormone she was allowed: generic Premarin. Take it or leave it.

This doesn’t mean you can’t have these functional tests performed or get your bioidentical hormones made up. What the network is saying is that these tests and hormones have been excluded as an in-network benefit. In other words, they’re not covered. This is why it’s useful for you to know something about out-of-network coverage.

The upside of in-network providers
When you, the patient, select a physician in your insurance company network, you have the real advantage of knowing that once you’ve met your annual deductible and co-pay there won’t be a lot of surprises when it comes to costs. If you keep yourself healthy, you’ll probably not even notice that it’s taking longer and longer to get an appointment or that your doctor visit seems shorter. If you’ve got chronic medical problems that require constant monitoring (like insulin-dependent diabetes or cancer chemotherapy) and you need to see a physician frequently, having a network physician is definitely more economical.

But I’ve discovered that most patients don’t fully understand what it means to see a physician who’s not in their network or why they should even consider it. Yes, it costs more. But generally, sort of like buying new tires or paint, you get what you pay for.

The two types of out-of-network practices
A small but growing number of out-of-network physicians have reconfigured themselves as “concierge” or “boutique” practices. You’ll see more and more of these in upper income, especially urban, areas of the country. It’s estimated that 8% of primary care practices will shift to concierge style over the next few years. The concierge physician limits herself to a small but fixed number of patients, usually less than 300, and she charges an annual fee, anywhere between $500 and $3,000 a year. For this she agrees to be accessible 24/7, get you in for an appointment within 24 hours, and to spend more than the usual 5 minutes with you at that appointment.

Clearly you need to be fairly well off to enter a concierge practice. If you’ve got the money, however, you may as well enjoy some of its perks.

It’s important to know that patients in a concierge practice still need to maintain their conventional health insurance (though they often save money by selecting high-deductible or even HMO plans), which is used to cover any labs, x rays, emergency room visits, hospitalizations, or specialist referrals.

Far more common than the concierge practice, however, is the out-of-network physician who bills your insurance company for a portion of the medical services she provided. When her bill arrives with your insurer, they immediately see she is not one of “theirs” and reimburse her according to the out-of-network guidelines in your policy. People rarely read their health insurance policies, but were they to do so they’d discover a whole section devoted to this. Like your first in-network bills each year, with any out-of-network expense (such as the bioidentical hormones or food sensitivity testing in the example above) there’s always a deductible to be met first. To discourage you from using out-of-network providers or uncovered benefits (like food testing), your insurer usually prices the out-of-network deductible a bit higher.

At the time of completing your visit, an out-of-network practice will ask you to pay a portion of your bill (usually about 30%) and then bills your insurance company for the difference. Virtually always, once your deductible is met, your insurance company will kick in something toward your bill. Then, sometime later, you’ll receive a bill from the out-of-network practice for the difference. This is called balance billing.

What most patients don’t realize about out-of-network practices is that the bill you receive from the practice applies only to professional fees and uncovered lab tests (like food testing, salivary hormones, etc). Your physician will order routine lab tests and virtually all x-rays, CT/MRI scans, hospital admissions, and specialists to be in synch with your network. Patients worry that by seeing an out-of-network physician everything else will be out-of-network as well, but this is not the case. Half of our patients at WholeHealth Chicago are out-of-network and we’re very conscious about using the appropriate lab for that patient’s particular insurer when the test is a covered benefit. Think this sounds complicated? It is! However, this policy makes going out-of-network much less a financial burden than you might guess.

Some aspects of health care will always not be covered by your policy, no matter who’s insuring you, such as certain lab tests like food sensitivity testing, vitamin levels, or the functional labs that test digestion or how well your liver removes toxins. These functional tests are available only through out-of-network labs, but even in these cases (to the pleasant surprise of patients) your out-of-network benefits cover the lion’s share of costs.

One very much overlooked aspect of using out-of-network care is to tap into any Health Savings Accounts (HSAs) that might be offered by your employer. Many patients contribute to their HSA, drawing on it to cover out-of-network expenses. With a good HSA, you might discover your out-of-pocket costs between in-network and out-of-network are pretty much the same.

What I recommend

  1. If you’re in-network somewhere and happy with your in-network doctor, then stay there. If you’ve got a medical problem like high blood pressure, heart disease, or diabetes and you need frequent visits, this is by far the most economical and efficient way to set up your health care.
  2. However, if you sense something is missing from your current provider it’s time to consider a change. That missing something might be the length of time your doctor spends with you (“I’m only seen for five minutes”), attentiveness (“she sees so many patients I don’t think I’m being listened to”), concern about preventive care, referrals for alternative medicine, or interest in/knowledge of nutrition. Or it simply might be that you’ve been feeling crummy for a long time and keep hearing “we can’t find anything wrong with you.” If this describes you, seeing someone out-of-network might be a better decision.
  3. Understand that in the current system, you already have two insurance policies combined, both in-network and out-of-network. Many patients simply use both as the need arises. They’ve got an in-network primary care doc for sore throats and upset stomachs, wellness exams, and Pap smears, and an out-of-network provider for chronic symptoms that get the short shrift in a busy in-network office.

What’s in store for WholeHealth Chicago
As most of our patients know, we’ve been out-of-network with every insurance company except Blue Cross since we’ve been in existence. Our style of practice–long visits, functional testing, integrative care, and understanding the mind-body connection–have always set the collective Blue Cross teeth on edge. (“You guys really believe biography affects biology? Give me a break!”)

As I mentioned in last week’s Health Tip, Blue Cross recently started sending us mailbags full of letters asking why we’d ordered vitamin levels, why we needed to spend so much time with patients–why, why, why?

Let’s just say our current relationship with BC/BS is dicey, especially at a time when the phrase “narrow network” is being bandied about. To them, and to all health insurers, the ideal in-network doc works fast, orders the same teaspoonful of tests (blood count, metabolic and cholesterol profiles), renews the patient’s statins, blood pressure meds, and antidepressants for another year, and reminds the patient to lose weight and exercise more. Next patient, please.

From the BC/BS point of view, with 30 million new enrollees at the gates it’s looking for speed, not comfort. Speed? That’s not us.

Be well,
David Edelberg, MD



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