What Happens When Your Doctor Doesn't Take Your Insurance Anymore

Scenario: In October 2010 during open enrollment time for Medicare Advantage programs in the USA, Mary Spivak's Medicare Advantage plan informed her they were going to raise her monthly premium $25 and raise some of her co-pays on services that she used often, like her monthly blood work.

After talking to her friends, they said it was not worth it to stay with the plan when so many other plans would cover her for much less cost or some were free. Her monthly blood work could be very pricey. So Mary made the decision to change her Medicare Advantage insurance plan.

When she did some research on her computer on Medicare's website, it was boggling when she was confronted with a list of over 50 plans in her state alone. Trying to compare each plan's coverage to get the best plan was information overload to Mary. How do people decide what plan to go with?

She narrowed it down by importance:

• to make sure that her present doctors were on the list of whatever plan she picked because she has been going to them for a few years and she liked them. She didn't want to get to know a new doctor and acclimate him to her medical issues.
• to keep her monthly premium low or free
• that her monthly blood work was free or had a copay she could afford
• that her daily medications were covered with a low or no copay.

Mary got to work dissecting each plan's coverage. After a few hours, her choice ended up being XYZ's Medicare Advantage Plan because their coverage suited her needs, all her doctors were on their provider list and the plan had no monthly premium in her state. As long as Mary continued to pay her Medicare Part B premiums, the plan was free. Mary always likes getting something for free.

Author's note: This hub is not an endorsement for any Healthcare medical plan. XYZ Healthcare Plan is only used as an example.

A month later, in November 2010 the letter that came with Mary's XYZ Healthcare Identification card read: "This patient has been approved for the 2011 enrollment year on the XYZ Healthcare Medicare Advantage Plan."

Mary breathed a sigh of relief that the headache of choosing the right Medicare Advantage health care plan was behind her.

Fast forward to a year later in October 2011.

If you are like Mary, you are very happy with your doctor, your care and the way the plan pays your bills after you pay your co-pay. All seemed fine in Mary's world until she received a letter just before open enrollment time for the 2012 year.

"This letter is to inform you that Dr.(name) will no longer be a participating member of XYZ Healthcare Plan as of October, 31, 2011. You have been assigned to Dr. (name) and your signature is required to have your health care records forwarded to their office. Please contact them at (phone number) to make an appointment after November 1, 2011. If you would like to make another choice of physician for your health care needs, please refer to Our Physician's Directory. Please be sure they are accepting New Patients before you notify us of your choice. A new identification card will be issued to you after November 1, 2011 with the name of your new primary physician. Allow 10 days to receive your new card."

Just reading those words boiled Mary's blood.

She purposely chose a well-known name plan like XYZ Healthcare so there was a good chance that her doctors would stay with the plan. Many of her friends had the same plan. XYZ even lobbied for senior citizens in Washington D.C. A representative spoke to Mary's senior group to explain what they were doing to support of senior citizens. And now this.

Mary had established a good relationship with her primary doctor over the last few years. He "knows" her, "knows all about her medical issues" and follows through on all her tests and referrals to other doctors. And now he is suddenly no longer taking her insurance?

Mary Spivak was damned mad! How dare he!

In early October 2013, AARP UnitedHealthcare dropped massive numbers of doctors from their plan.

Within days, other insurance companies began to do the same thing. Many USA citizens blamed Obamacare for the actions of insurance companies.

AARP UnitedHealthcare (as well as a few other plans) decided to address their problems by turning the tables.

Since they can't drop their sickest and highest maintenance patients from their plan because of the possibility of lawsuits, they have chosen to drop the physicians who are ordering the high-cost services for those patients.

The patient is the one who suffers. However, this article has a solution where patients get to keep their doctors and still have a good health care plan they can afford, while still meeting their medical needs.

Do you think your doctor cares more about making money or providing good health care to you?

You'll be surprised to know that most doctors care more about providing good care to you.

They just like to know that somewhere along the line, the insurance plans will pay them enough to be able to stay in business.

Mary was loaded for bear when she got to her doctor's office. As soon as he came into the exam room, she waved her letter in his face, filled with so much anger and frustration that he would do this to her.

Mary told him, "Doctor, I thought you and I had a good relationship after three years. I thought you cared about me as a patient. You've called me at home to make sure a new medication was working or to see if I made an appointment with someone you referred me to. I thought you cared!"

He told Mary to sit down and calm down, to let him read the letter. She could see his facial changes as he read it and he didn't look any happier than about it than she did.

He excused himself, went to his office, and came back to the exam room with a letter of his own. He handed it to Mary to read:

"This letter is to inform you that you that XYZ's Healthcare Plan is amending your Agreement with us as a health care provider to discontinue your participation in our network, effective October 31, 2012. Your termination is "without cause," because your contract with us permits our company to take this action. Your affected patients under our XYZ Healthcare Plan will be contacted under separate letter to be assigned to a new physician, effective November 1, 2012."

After Mary read his letter, she asked him, "What's this game the insurance company is playing? And how many patients are they talking about?"

He said, "Mary, if you read your letter again, you can take the wording two ways. It says I will no longer be a participating physician with XYZ's Healthcare Plan. What your letter doesn't tell you is that I wasn't the one who made that decision."

Mary said, "I can't believe they kicked you out. Why? You are a wonderful doctor!"

He said, "Thank you, but that is probably a contributing factor to their decision. You see, these plans are hoping to have more 'well patients' - patients we see once or twice a year for checkups, flu shots, preventative tests, and screenings. The companies play the law of averages that if a patient gets regular checkups and screenings, he is less likely to come down with a serious illness in future years."

Mary said "That's silly. Anyone can get sick no matter how well they take care of themselves."

He said, "That's true, but they have a formula they use which tells them that this way of providing health care has saved them money. 'Well patients' don't need a lot of tests like MRI's, frequent blood work to monitor medication performance, and other expensive medical care. That is costs are kept low and insurance companies save money. They are hoping to collect premiums from a lot of 'well people' against the payouts for a few 'sick people' to keep them afloat."

Mary said, "I don't know too many people my age who are 100% well, and who don't need a referral now and then to make sure what they don't have something more serious. I just got two referrals from you last month to specialists for a stress test and to get that strange skin lesion on my back looked at. Aren't you supposed to give referrals?"

He said, "Yes, I have to give referrals to specialists if I think you need one. I can only do so much within the scope of my training. I can order tests for you but ultimately you still will have to follow up with a specialist for continued care of that problem. What I'm saying is that the insurance company can't drop you, the patient, just for being sick or for causing them to pay your high medical bills. Patients would sue for discrimination. So the insurance companies have taken on a different line of attack.

"They are now dropping doctors who don't have enough of XYZ's patients on their medical plan. If I had 150 patients on their plan, they might keep me. But the least number of patients I have who are insured on their plan, the less amount of money they pay me per patient per month for my stipend. They try for a package deal if we have a lot of patients on their plan, which means they are paying less per patient for a lot more insured patients.

"What you don't know is that I only get paid a small amount as a stipend for each patient. That's why I cannot spend 20 or 30 minutes in each room. I have to keep moving so that I see at least 5 to 6 patients per hour. The insurance company might only pay me $20 per patient on Plan A and patients who have Plan B maybe I'll only get $15 for each one. So in an hour of seeing 6 patients, I am paid between $80 and $100. I am paid $25 for 'sick patients' who require more time per appointment, no matter what is wrong with them."

"They are punishing you?"

"That is exactly what they are doing. We establish good relationships with our patients who grow to like us and trust us to give them good care. But the insurance company doesn't take into account all the uninsured people that we treat who are walk-ins or the amount of time we spend with 'sicker patients.'. We can afford to treat the walk-ins for free because we know we'll make up the difference with the stipend we are paid for all the other patients under our care. The letter is not fair to us and it is not fair to the patient to disrupt their care and to assign them to new doctors to start all over again. I understand you are angry, Mary, but I am just as mad."

Mary Spivak was feeling a little sheepish for yelling at him, now that he explained it.

He said, "The letter they sent you makes it look like I did not want to be a member of the Plan anymore and that I just decided to stop taking their insurance when that is nowhere near the truth. The insurance companies dictate what kind of care I give, how much and how frequent and even which doctors I have to refer my patients to who are on their Plan."

Mary said, "When I signed up, I was told my quality of care would not be changed - but if I lose you, it will be changed! They lied to me! I go do all that work checking coverage between insurance plans and now the insurance company can change it all? That's not fair to do that to me and it's not fair what they are doing to our doctors. We can't help it if we are sick, that's why we have insurance! Many people are not sick ALL the time, so we can't be costing the insurance company money ALL the time."

He said, "Mary, with the other 3 doctors here, we have about 40 patients on XYZ's Healthcare Plan and every single one of them got the same letter you did. That's 40 patients who are being assigned to new doctors next month."

Mary saw a vicious circle forming. "So what can we do about it?"

He smiled and "I'm glad you asked! You have a lot of friends, Mary. I can sure use your help."

He said "The solution is simple. Turn the tables back again. We just have to get the word out.

"Instead of choosing a doctor from Medicare's list, choose a Healthcare Plan from the doctor's list.

"If you like the primary doctor or specialists you have, go to the doctor's office manager and obtain the list of Healthcare Plans he accepts. After you get the list, see which of the top three plans have the most patients.

It is less likely that Plan will drop the doctor for lack of participation if he has a large patient base for that insurance plan. If the number isn't listed, the office manager will be allowed to give you an estimate. If he/she won't tell you, ask your doctor. He knows which companies pay him the most so that will be the Plan who has the most participants.

"Go on the computer and check out the coverage for each plan and pick the one that closest fits your needs and is affordable to your budget. Call the Plan and change over before enrollment period ends," he said.

Mary said she would be glad to help.

After the first day of talking to people, she found that implementing the solution was more work than one person could handle. She needed to call in some of her friends so more ground could be covered more quickly.

Mary Spivak had lots of connections with senior citizens, the main target of Medicare insurance plans. She belonged to several senior citizen groups in her city, a church with a big congregation, plus a Bible study group. A few of her friends also received letters and after Mary explained: "Drop The Plan, Not The Doctor" they too decided to go speak at their senior centers and church groups.

Mary read XYZ Healthcare's letter to her senior group, then she concluded,

"As patients, we don't have to agree with the letter from the insurance company that is dictating who will be our doctor and what kind of care we get. Now, because insurance companies are dropping our favorite doctors from their Plan for not having enough patients on that plan, patients can choose to keep their doctor and get rid of the insurance company. And here's how ...."

As she explained the solution, many heads nodded in agreement.

"You are in the driver's seat as to which health insurance company you choose, the same as you are in the driver's seat as to which doctor you choose.

"I urge you, "Drop the Plan, not the doctor."

As she sat down, Mary thought it was kind of poetic justice, beating the insurance company at their own game.

When she got home, Mary called her doctor, "At the beginning of the meeting, they knew they were going to lose a doctor they liked and be assigned to someone they didn't know. They didn't like it any better than I did. At the end of the meeting, they agreed. Drop The Plan, Not The Doctor."

Consider the following:

• If you have a doctor you like (or love), make every effort to keep him by choosing a Healthcare Plan that he accepts that has a large number of patient subscribers. Don't let your present Plan have more leverage over you by telling you that you have to accept their physician choice for you.
• Keep in mind that you cannot talk to an insurance company. You can talk to your doctor.
• Keep an eye on the payments that your Plan makes on your behalf and how much you have to contribute to the cost. Decide if your co-pays are acceptable to you.
• Talk to other patients in the waiting room. You'll be surprised how much people will share with you when they like their doctor and also when they hate their doctor! Ask about their Healthcare Plan, see how they feel about their Plan, coverage, and premiums if any.
• You can keep your plan from year to year without shopping for a new plan as long as the coverage is acceptable to you.
• Usually something changes on a plan each year. It might be the patient's co-pays, the referral process, physicians adding to dropping from the Plan. It is a good idea to keep up to date on what the other plans are offering by taking a look at their websites during each enrollment period. That way you will know if your Healthcare Plan continues to be a good fit for you.

If you receive a letter from your insurance company as Mary Spivak did and like her doctor did, what will be your decision? Your comments are welcome.

Thank you for reading and I hope I have enlightened you about your choices.

Note: Mary Spivak's name was changed in the interest of privacy.

Published April 2013 by awordlover

November 2, 2013 - This article has been edited to replace videos.

June 2019 - Article has been updated