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Figuring Out the Health Plan Puzzle


With payer complexities so burdensome, I can see why some physicians forgo health plans altogether.

It has become harder and harder to figure out what plans my practice participates in. Once upon a time, it was pretty straight forward. If you participated in Horizon Blue Cross, if anyone had a Horizon Blue Cross plan, they were covered. But that is not true anymore.

Now each insurance company has these little niche plans. In the last year, we received about three letters saying that while we are still participating providers for Big Insurance Company X (BCIX), we are not providers in BICX's new special little plan because we do not admit to a certain bigger university-affiliated hospital. There are "inner circles" and "preferred providers." We are in some but not others.

And there are managed Medicare and Medicaid plans. And we are providers for most Medicare plans, but not all. We do not accept Medicaid. Sometimes patients will just say they have Private Insurance Y (PIY), but in reality they have PIY's Medicaid plan. My staff knows now to specifically ask patients if it is a state or "government" plan.

And now there are new plans; plans we have never heard of. Some are affiliates of companies we are familiar with. Some are completely foreign to us. Patients call and ask us if we participate, and my staff is often at a loss. Sometimes they can find the information online, but not all the time. And calling the company (if we can get a phone number) is a giant black hole of time. And while we ask patients to call the company to find out, we aren't always sure they get accurate information, or even really made the effort to find out.

I can understand why some physicians decide to forego participating in any plans at all. The complexities of the system are becoming so burdensome. I can only hope that things get better in the new year. 

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