You should know and understand your insurance policy. What is your insurance company? What is your in-network policy – deductible, copayment/coinsurance, out of pocket maximum? What is your out of network policy – deductible, copayment/coinsurance, out of network maximum? Are your doctors in network or out of network?
If you’re seeing an out of network doctor, you may have to pay a bit more attention to your policy. If you’re getting a procedure, you may have limitations in your policy (like you can only get a certain number of procedures per year), or require prior authorization. In order to find that out, you will need your doctor’s NPI (National Provider Identification Number) and the Procedural Codes (also known as CPT codes). You then have to call Member Services (usually you will find the number on the back of your insurance card) and ask them if there are any limitations or authorizations required for said CPT code.
If you see an out of network provider and they don’t tell you that they are out of network, you are protected by the No Surprises Act. This means you would only be responsible for in-network costs. However, please note that every state has its own protections so please check with your state’s specifics! This scenario happens mostly in two areas – in the emergency department/hospital, or with anesthesia from a surgery. Let’s say you’re in the emergency department and you need a specialist to consult on your care, and the specialist is out of network. Unless you were specifically advised that they are out of network, you would not be responsible for additional payment (outside of your normal in-network costs) for seeing this specialist. Also, because you saw this specialist as part of your emergency care, your insurance company should cover the cost of this specialist.
Knowing and understanding your insurance policy is important!!
Filed under: pain management
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