The plan’s directory says your cardiologist is in the network. In January the practice says otherwise. Both statements can be true at different moments, and the one that counts is the one at the appointment.
Directories are snapshots. Contracts change, practices leave, and the website catches up when it catches up. Here is how to check properly, in about twenty minutes, before you commit to anything.
Make the list first
Write down every clinician you actually see, with their full name and the name of their practice or group.
Include the primary care doctor, every specialist, the practice you would use for anything urgent, and the hospital you would want to be taken to. If you are seeing someone for a course of treatment that will continue into next year, put them at the top — an interrupted course is far more disruptive than a routine visit.
Names matter more than practice names. A large group can be in a network while an individual physician within it is not, and the reverse also happens.
Step one: the plan’s own directory
Search by the clinician’s name, not by speciality. Confirm the location as well — a doctor can be in-network at one address and out at another.
Note the date the directory says it was last updated, if it says. Take a screenshot or print the page. It is not a contract, but it is evidence of what you were told when you chose, and it has value if you later need to argue.
Step two: telephone the practice
This is the step people skip, and it is the one that actually answers the question.
Ask the person who handles billing, not the receptionist taking appointments. The question to ask is precise: “Are you contracted with” — plan name, and the specific plan, not just the insurer — “for the coming year, and are you accepting new patients on it?”
Two answers, both of which matter. A practice can be in-network and closed to new patients on that plan, which for a new arrival is the same as being out.
Write down who you spoke to and when.
Step three: telephone the plan
Ask the plan the same question about the same doctor. If the plan and the practice disagree, you have found a real problem before it cost you anything.
When they disagree, believe the practice. They are the ones who will submit the claim.
Step four: check the hospital separately
Your doctor’s network status does not settle your hospital’s. Nor does the hospital’s settle the network status of the anaesthetist, the radiologist or the pathologist who works there.
If there is a particular hospital you would want to use, check it by name. If you are planning a procedure, ask the surgeon’s office whether everyone involved is in the network. It is a normal question and they are used to it.
What is different with Original Medicare
If you keep Original Medicare and add a supplement, there is no network to check. Any provider who accepts Medicare will see you, anywhere in the country.
The question changes to whether a provider accepts Medicare at all, and whether they accept “assignment” — the Medicare-approved amount as full payment. Most do. A small number do not, and some have opted out of Medicare entirely, in which case Medicare pays nothing towards them.
It is a shorter conversation, and for people who travel or who value not having the conversation at all, that simplicity is a large part of the point.
Do it again every autumn
Networks are rebuilt annually. The doctor who was in-network this year may not be next year, and the notice of it will be in the Annual Notice of Change that arrives in September.
Once a year, take your list and repeat steps one and two. It is twenty minutes, and it is how people avoid discovering a change in a waiting room.
If a doctor leaves the network mid-year
It happens. If you are in a course of treatment, ask the plan about continuity-of-care provisions — plans are often required to let you finish under specified circumstances. Ask early and put the request in writing.
A network change may also, in some circumstances, open a window to change plans. It is not automatic. Telephone the plan and ask directly, and telephone 1-800-MEDICARE or your State Health Insurance Assistance Program if the answer sounds wrong.
The short version
Search the directory. Telephone the practice’s billing office. Telephone the plan. Check the hospital separately. Write down who said what and when.
Twenty minutes in October is worth a great deal more than an afternoon of telephone calls in February.
General information, not advice
This guide describes how Medicare generally works. It is not advice about your situation, and rules, dates and figures change — verify anything that matters to a decision against Medicare.gov, 1-800-MEDICARE, or your State Health Insurance Assistance Program, all of which are free.
Rights and rules vary by state; this describes Ohio, Kentucky and Indiana. TAVA HEALTH, INC. is not connected with or endorsed by the United States government or the federal Medicare program.
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