3. Total out of pocket for the year. This is an important number to find out when you buy a policy and keep in mind. This is the maximum you will pay out of pocket in addition to your monthly premium. This number tell you a lot about what you will be responsible for on top of your premium. Always read the fine print in the contract which is what counts and not what the insurance sales person tells you! Remember he/she want to sell you a policy!

      4. Panel of doctors you can go to. Just like you choose what health insurance plan to buy, also doctors, physical therapist etc. choose what insurance company they want to contract with to provide services to their patient. So be careful. Your present doctor, who you may have gone to all your life, may not participate with the insurance they are trying to sell you. If that is the case you will have to pay him/her out of pocket or change doctor.  Why do some doctors not participate with certain insurance products? Because sometimes you are working for pennies on the dollar or because the company has made it very difficult to follow their rules, etc. Your policy may have out of network benefits, but usually that means that your deductible and/or copay/coinsurance are going to be higher if you go to a doctor who is out of network.  

      5. The doctor’s side of the equation. When a doctor signs to participate with an insurance company he agrees to two things. Reduced payment and agrees to follow the insurance company rules if the doctor want to get paid. When these agreements are signed the company benefits from the doctor by having to pay him less but also since we agree to follow their rules, they also want to dictate what we can do to you if we want to get paid. And even when or if we can do this or that treatment to you. I will give you an example.

Let’s say you come to my office because I participate with your particular insurance company and you are complaining of severe lower back pain radiating down the right leg down to your toes with numbness and tingling for the last two weeks. You are really uncomfortable. I do a physical exam and I conclude that you most likely have a herniated lumbar disc. To confirm my diagnosis, I need to order an MRI of the lumbar spine. However, your insurance requires that I need to call the insurance company to get this test authorized (a waste of time for my staff and I). When we call, a nurse says that, before they approve that test you need to undergo six weeks of physical therapy and medication management. They don’t give a crap that you are in severe pain and they don’t care that the therapy is going to cost you money. The bottom line is they have saved money by not paying for the MRI and they have wasted my time and prevented me from making an accurate diagnosis and treating your pain.  Who suffers with the pain? You do! The only way to bypass this is by you agreeing to pay for the MRI and any other treatment out of pocket.

What does the doctor get by signing up with any insurance to be a participating physician with them? What they get is that patient with that insurance can come to the doctor and he gets paid. BUT ONLY IF WE FOLLOW THEIR RULES. It takes a lot of manpower to deal with insurance companies and their payments are getting lower and lower. For that reason, some of us are cancelling our participating agreements with insurance companies. I just cancel my agreement with UHC. Every year we get cuts in payment from one or another insurance company while all our expenses keep going up and up. Here is what Medicare just announced!