Who's responsibility is it to notify you when your insurance co drops your dr?

Question

We have been going to the same dr, and we have had the same insurance, for years. I went yesterday and found out they are no longer a participating dr. Therefore that visit, and my previous one, was considered 'out of network' and I had to pay 60% of the cost of the visit- rather than the 20% I would have paid normally. I feel the drs office should have notified me, or at least informed me at my last visit. Does anyone know who's responsibilty this was? Am I supposed to get online and check the status every time? If so, my insurance company should have told me that I had to -

Answer 1

It is the responsibility of the patient to find out before the services are rendered if the provider is in the network. It would be impossible for insurance companies to notify you everytime a doctor terms their contract. It happens too often to notify the insured when this happens. Most insurance companies will have providers listed on their web and you should always double check prior to making an appointment. I do feel however that your providers office should have told you and I would contact them and see if they would be wiling to settle with you on that particular claim. Another trick is to contact your insurance company and tell them that you found the provider listed on the website the day the services were performed. Sometimes based on this they will allow the services as in network on a one time basis. Many times the websites are not updated to the day and providers aren't removed as quickly as they should be which is why insurance companies will make the one time exception. Check on the web today and see if the provider has been removed. Another thing you may want to ask your insurance company is if they offer transition of care on your plan where you can continue to see a provider for a certain length of time after they terminate from the network. Some insurance companies will allow time to find a new doctor. You would have to contact your insurance company to find out for sure. Good luck!

Answer 2

As a patient, it's really your responsibility to know your own insurance. It would have been a nice courtesy for the provider to let you know they no longer are in network with your plan, but since many providers deal with hundreds of plans, it's not always possible. (My office deals with over 300 separate payors alone.) It also would have been nice for your insurance to send out a letter or an email saying "Effective your selected PCP is no longer in network..." But that would require an insurance company to be smart, and most of them are not.

Answer 3

State laws vary; for example, in my state, there is a law requiring the insurer to notify you if your PCP is no longer participating. The PCP must continue to see you for 90 days after the participation agreement termination, and accept the insurer's payments as payment in full. Not all states have such a great law.

Call your state insurance commissioner's office for a definitive answer.

Answer 4

Hello There!

My family doctor was dropped from our Health Insurance Carrier at one point, and he informed us immediately. His staff informed all the patients who had this insurance provider.

We all wrote letters and he was re-instated. So, the doctor's office should have told everybody so that they could take action.

Answer 5

Nobody's. It's up to YOU to call the number on the back of your card, and verify that your providers are IN NETWORK, before EVERY VISIT.

Somewhere in your policy, it tells you that. I know, no one EVER reads it. But it says it.