Most everyone knows that if you are enrolled in a PPO, you need to use a network provider to receive maximum benefits. What you may not know is your physician/hospital may use other providers that are not in the network, ie., if your physician sends your lab work to a facility that is not in the network, the charges may be subject to a higher deductible and coinsurance. Makes a difference when the bills start coming in!
It has been our experience that most people make the effort to assure their physician/hospital is in the network, but don’t realize that some of the services they will receive can be provided by non-contracting providers. Some of these services are: lab work, interpretation of lab work, emergency room doctors, second opinions and anesthesiologist.
Example: You have injured your knee and require surgery. You make sure the doctor is a network provider and the hospital is also in the network. Do you think you have taken care of everything you need to? Wrong!
Will there be an assistant surgeon and are they in the network? Is the anesthesiologist a network provider? If you require physical therapy after surgery, is the physical therapist in the network?
There are still questions to ask in order to assure you will receive as many services as possible from network providers/facilities.
Experience has also taught us that even though an association of providers is considered in the network, that does not mean every physician in the association is a network provider. Example: XYZ Anesthesia is a association of anesthesiologist contracted with ABC Insurance Co. However, not every anesthesiologist employed by XYZ Anesthesia is a ABC Insurance Co. network provider. You will need to make sure the anesthesiologist handling your procedure is a network provider. If not, your medical services will be subject to out of network benefits making them subject to a higher deductible and coinsurance.
The moral to this story is to make every effort to assure you receive services from network providers and facilities. Ask questions about who will be providing your medical care. It may take a little more time and effort on your part, but will very likely save you money.