Health Insurance Providers and Claims – What You Need to Know


Health Insurance Providers and Claims – What You Need to Know

Michelle Zimmerman shares an article on what you may not know about insurance providers and healthcare.

We all know that provider networks matter in healthcare. We understand that insurance products with both in-network and out-of-network coverage are more expensive and that if we want to keep our existing providers we should carefully check whether each doc is in network before selecting an insurance plan. 

This basic understanding may once have been sufficient to protect us, however, this is no longer the case. I have thought about these issues for a while — and experienced them myself as a patient — so thought I would share.

  1.   Just because you have out of network coverage does not mean you won’t pay!

Health insurers set the reimbursement rate for out-of-network claims. In the past, the rate of reimbursement was generally “usual and customary” – which basically means – the reasonable cost of care in a particular geography. This year, most of the products are quoted at % of Medicare (usually 140%) —- this is low. I mean really low.  Bottom line — if you go out of network with one of these plans, most of your cost of care will not be covered – this means higher out of pocket costs. Given this, it may not make sense to purchase a higher premium product with some out of network coverage unless you know you will drain your out of network deductible and out of pocket max.

  1.   Hospitals and the providers who work there often bill separately and don’t always share the same insurance

This issue has been widely discussed in the press but let me recap here. For example, you walk into an ER and you speak to the attendant who informs you that hospital is in your network.  Would you know to ask whether the physician treating you in the hospital is also in network? Probably not. Well the government – at least in NYC. But not all states protect against this so make sure to ask whether each provider you are seeing is in network.

Oh…and this also goes for blood work, medical imaging and other ancillary services. Your providers network might not align with your insurance company’s network so be sure to ask.


Key points include:

  • Out-of-network claims.
  • Providers changing networks
  • Deductibles and out-of-pocket maximums


Read the full article, Your healthcare network matters – A LOT, on LinkedIn.