How do I know if my patients are in-network?  Simple question with a not so simple answer…

As a medical billing company we get this question all the time from our plastic surgery and dermatology clients…and it isn’t always easy to answer.  Is it impossible to have an insurance contract plan list by insurance company for your front office to reference?  No, that’s actually a great idea.  That said, do you want your staff communicating definitive information regarding how an insurance company will behave over the phone or at the first contact point with your patients?  You already know it will come back in the form of a complaint if the information isn’t accurate regardless of why the information didn’t pan out.

Insurance plans come in different types, each with their own fun acronym like PPO, HMO, EPO, POS, etc.  Throw in the different networks and sub-networks for each different insurance company and you’ve further muddied the waters.  Then we add on the plan names that each insurance company uses to market their offerings, which don’t always directly indicate the network, or plan type etc. and things just become unmanageable.  To be able to identify network status from the front of the insurance card a patient just handed your reception team at check-in, with the waiting room full, or the “Gold Plus Supreme Insurance Plan” the patient just mentioned, while scheduling that consult, while the second and third line are buzzing is just not always feasible or fair to expect.

So what is the best way to handle offering accurate information to your patients, not overwhelming your staff and keeping yourself off the hook for the “I’m not paying my bill you told me x, y, z?”

Here’s what we suggest…

1)    Know your insurance networks at least on a broad basis – you can’t just not know which companies you’re contracted with.  Have a cheat sheet for your front office, patient care coordinators and other staff that don’t deal in the minutia of insurance all day.

2)    Make sure your medical biller/medical billing team/medical billing company knows those details.  You should have a contract list available that shows who you are contracted with, which plan types, which IPAs (HMO groups), and what your rates are for each.  Should they be able to tell you if that “Gold Plus Supreme Plan” is in off the cuff, not necessarily, but they should be able to find out.

3)    Have anyone in your office that gets the “is my plan in network?” question repeat after me:  Dr. Auctus accepts (insert broad insurance company names here – e.g., Aetna, BCBS, Cigna, Humana, Medicare and UHC), but we do recommend that your check with your insurance company ahead of time to be sure.  Your staff have just been helpful to your patients, but have not taken on the liability from committing to a yes or no.

You will get patients here and there that will push for more definitive information and this is where your resident office insurance guru or guru service (*nudge nudge we can help here) can come in handy to quell the concerns.  The key is to be able to offer an informed and helpful response while still making clear that your office is not taking responsibility for providing network status and thus taking on liability for payment.

If you are interested in seeing what a contract grid sample looks like or would like assistance in developing one, we are here to help!