All About your Doctor (and his office)

Your doctor should know all about you and likewise there are some things that you should know about your doctor.

If your health insurance is with an HMO, you should know if he is a primary care physician for your particular HMO. If your insurance is with an HMO, you should know that only your primary care physician can refer you to a specialist. You should also know that your doctor would much prefer treating patients than filling out forms. Unfortunately, with the managed care health system many doctors are spending more time doing paperwork than they are in seeing sick patients. They don’t like it either, but they do not have much control over the paperwork bureaucracy mess, to put it bluntly.

If you are eligible for Medicare benefits, you should know that your doctor has no control over what he charges you. Please read that sentence again, --, “Your doctor has no control over what he charges you if you are on Medicare”. Congress votes every year as to whether or not doctors fees will be increased, decreased or remain the same and the Medicare carrier (the insurance company hired by the government to process Medicare claims for each state) is then responsible for sending a fee schedule to every doctor. God help the doctor that does not charge exactly the way it is listed on the fee schedule.

You should know if your doctor is participating in a PPO (Preferred Provider Organization) it means he signs a contract with the particular PPO insurance plan and agrees to accept reduced fees. If a doctor is in a PPO plan it means he is “in network” for that particular plan and he can only charge you based on the contract fees that he agreed to with the particular PPO. If your doctor is not in the network, he can charge whatever he would like.

In most cases, your doctor is an expert in taking care of you when you are sick. If your illness is not part of his area of expertise, he will refer you to a specialist. Expect that of him. Do not expect your doctor to be an expert in understanding your health insurance or anybody else’s health insurance.

There are so very many different health insurance plans on the market today, that it is virtually impossible for your physician and/or his staff to stay current and understand how all of the insurance plans work. Horizon Blue Cross/ Blue Shield of New Jersey has more than 80 different plans, so you cannot tell your doctor’s staff that you have Horizon BC/BS of NJ and expect them to understand just which plan you have. Understanding your health insurance is your responsibility and it is your responsibility to explain it simply, quickly, and briefly to the doctors billing person so that they can help you maximize your benefits.

In summary, be sure to ask your doctor questions that pertain to your health, your well-being, and your medications. Make sure your doctor or his staff is in the HMO or in the network if this is important for you. Do not expect your doctor or his staff to understand how your insurance works; it is not their responsibility.

Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance Claims, Inc. a health insurance services company . If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, or visit our contact page.