General, Specialized, and Preventative Care Part III

Insurance can play a huge factor in timeliness and comprehensiveness of care. For most insurance plans, there are a few main factors to consider when the need to see a specialist arises- PCP referrals and prior authorization, as well as which doctors are in-network and out-of-network. Although the latter generally applies to PCPs too, the universal nature of their role often means there’s not as much of a need to be selective in choosing one. On the other hand, if you have a relatively obscure or uncommon medical issue, it can sometimes be difficult to find a doctor that treats that specific issue, while also being in-network. What’s the difference between in and out-of-network? Specifics vary from one plan to the next, but usually, in-network doctors will either be fully covered by your insurance, or mostly covered. Out-of-net doctors either won’t be covered at all, or more commonly, your insurance will pay for a lesser percentage of treatment compared to in-net doctors.


 There are a few ways to find a specialist that’s in-network. Many insurance plans will have a list of in-network doctors, usually in a searchable database. If not, you can coordinate with your referring PCP’s administrative staff, or with the staff of a prospective specialist, to find out if they’re in-network with your provider. You can also “verify” your own insurance, meaning you can call your insurance company, and input your name, member ID, and (sometimes) group-number in return for information on your plan’s specific coverage. This is a good, proactive first step to understanding your own insurance plan, but it can be confusing; health insurance is very convoluted, often frustratingly so. Something very important to note is that, almost universally, calls to your insurance provider are recorded; there are a few reasons for this that can be for or against your benefit, but you should always ask for a reference number. Say you call your insurance to ask if a treatment is covered, and the representative tells you it is, 100%, but they’re mistaken and it’s not, or only partially. Now you’re sent a bill for $15,000 following treatment. You can appeal or dispute the charge on the basis that you were misquoted, using the reference number from the call. Even with this information, there’s not a 100% chance of winning the contested charge, but it’s a step in the right direction.


Please note that no part of this article constitutes legal advice; although these guidelines are very useful with regard to navigating the complex subject of private insurance, there can be many caveats and deviations to the information described herein.