In-network doctor vs out-network clinic/hospital ?

Question

As a foreign student visiting US, America's
insurance and health care system seems ridiculous complicated for me.

Especilaly I'm confused with some cases when doctor and clinic
are not in the same "network", one is in-network, one is out-network.

If I visited a doctor whose name I found from insurance
company website, then the doctor is in-network,
but the clinic he/she works is out-network.

Then I was charged extra fee of the clinic which will not
be covered by insurance company (docotor'serive was reimbursed
by insurance).

In the other case, I found an in-network clinic or hosiptal,
but as the clinic, I was treated by a doctor whose
name couldn't be found on insurance company' website,
so the doctor is out-network. His service could not be covered
by insurance company.

Are these two experience reasonable and possible ?

So I want to get a full insurance coverage,
do I have to be treated by an in-network doctor,
at an in-network clinic/hosiptal ?

Answer 1

Oh yes....that happens ALL of the time and it sucks! But, when you go to an ER or something with a hospital that participates (in-network), you can't exactly say, "I want a doc who is in-network". Well, ok...I've wanted to try that, but haven't.

You really don't see that in practices, exactly, but more so in larger settings like a hospital where you would get billed for the hospital bill and get the seperate bill from the doctor.

I don't know of a solution to that unless you try to specifically request an in-network doctor at an in-network doctor and see what they say. But, I highly doubt the regristration person will know who you will end up seeing let alone if they participate.

It isn't the insurance companies fault. It really is nobodys...it is just the way the system is. The doc has the right to choose who he/she wants to participate with.

I've been stung more than once..let me tell ya.

Usually, though, an insurance company will cover a percentage of a bill that is out-of-network.

Answer 2

Call your insurance company, tell them you went to an in-net dr and/or clinic, you have no control of the other party and ask if they have a clause in your policy to cover this situation.

Most insurance companies will take this into consideration and will reprocess your bills that were not originally covered. They may not pay it all but, something is better than nothing and it never hurts to call and ask.