Irrespective of the health insurance plan you have (domestic or visitors), irrespective of whether you are U.S. citizen or tourist, getting healthcare in the U.S. can be quite frustrating at times. It is just the unfortunate system of healthcare in the U.S. and not the fault of any particular insurance company or the patient.
What does PPO network mean?
PPO stands for Preferred Provider Organization. That is a directory of doctors, hospitals, labs and other medical facilities (collectively called providers) that have agreed to participate in a specific PPO network. Some insurance companies have their own PPO network while others use a common PPO network that various insurance companies share.
Are the providers in the PPO network required to accept the insurance?
Yes. The PPO network is not simply a yellow pages or internet search. It lists the providers that have specifically signed a contract to accept the patients from a particular PPO network. Not accepting the patients that have a particular insurance that participates in a particular PPO network when the provider is participating in that PPO network is a breach of contract.
When I called a provider from the PPO network directory, they said that they will not accept the insurance or they have never heard about this insurance. Why is that?
Make sure that you provided the name of the PPO network and not the name of the insurance product, insurance company or even the insurance agent/broker.
If you gave the PPO network name and if they still don't recognize, it is most likely due to the ignorance of the front desk staff. It is possible that they only know or remember the names of 2 or 3 PPO networks that they deal with every day and not all the PPO networks that the doctor is participating and signed the contracts with. Obviously, that is beyond the control of any insurance company.
If a provider in the PPO network refuses to accept the insurance, what should I do?
This does not happen often. However, in case it happens to you, you have several options:
You pay out of your pocket and file a claim for reimbursement.
You contact another provider.
You contact us and we will contact the appropriate person in the PPO network who will contact and properly educate the provider staff. In most cases, after such interventions, providers agree to accept the insurance and bill the insurance company to avoid a breach of contract and risking their contract with the PPO network be cancelled.
In some cases, a particular provider may have stopped participating in a particular PPO network without providing any notice to anyone. Even in that case, it is necessary that the PPO network becomes aware of it so that such provider can be taken off the directory.
I would really like to visit a specific doctor but his name does not come up in the provider directory. Can I visit that doctor?
Yes, you can certainly visit that doctor. These plans do not require you to go only to a in-network provider. Some times, a group of doctors work together and only one of the doctors signed a contract with the particular PPO network but any of the doctors in that group would see the patients and charge as in-network provider. (This is to avoid excessive paperwork for each doctor for each insurance company and PPO network). Some times, the doctor you want to see is really out of network. Of course, the exact situation can be figured out only when you call that doctor's office.
When I called a doctor in the PPO network, they said that they don't accept new patients. How is that possible?
Providers participating in a particular PPO network are not employees of the PPO network. Each provider runs his/her independent practice, decides work hours and decides whether to accept new patients or not. If their practice is too busy to accept new patients, that is beyond the control of any insurance company.
When I called a doctor in the PPO network, they said that the earliest available appointment is after one week. Why is that?
Each doctor makes his/her own schedule and availability. The insurance company has no control over it. Just because a doctor participates in the PPO network, it does not mean he/she would be available immediately. Just like you have the insurance, millions of others have the same insurance with the same PPO network. In addition to the insurance you have, the same doctor has signed up to accept patients from many other insurance companies. That adds up many more millions of insured people. You can see another provider or wait for that provider to be available according to his/her own schedule. Of course, please use your best judgment in selecting what kind of provider or facility is appropriate for your situation. More information at Choosing the Right Medical Provider.
It is very common that earlier available appointment to be able to see a doctor is after few days. The wait for a specialist may even be few months.
That is just the sad status of the healthcare in the U.S. and it is beyond any insurance company's control.
I called many doctors in the PPO network and all of them are saying either they don't accept new patients or they don't have any immediate appointments. What is going on? What good is this insurance if I can't use it when I need it?
That is the general problem with U.S. healthcare irrespective of the insurance you have.
This is beyond any insurance company's control.