What Happens When Your Doctor Doesn't Take Your Insurance Anymore
Without your health, everything else just falls apart
Choosing A Medicare Advantage Plan - researched by awordlover
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 up $25 and raise some copays on services that she depended, 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 premium or even for free. Her monthly blood work would be very pricey. So Mary made the decision to change her Medicare Advantage insurance plan.
When she got on the computer to research, it was boggling when she looked at the list of over 50 plans in her state on Medicare's website. To her, it was information overload trying to compare each plan's coverage to get the best plan. How do people decide what plan to go with?
She decided to narrow it down by importance:
- It was important to Mary to make sure 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 break in another new doctor with her medical issues.
- It was important that her monthly premium wouldn't break her fixed income budget,
- It was important that her monthly bloodwork would have a copay she could afford and
- It was important 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.
Stamp of Approval
The Letter From The Insurance Company
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."
Even with all her pre-existing conditions too, she marvelled.
Mary breathed a sigh of relief that the headache of choosing the right Medicare Advantage health care plan was behind her.
Fast forward to 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 your copay. All seemed fine in her world until Mary received a letter in the mail just before open enrollment time for the new 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 noting the name of the 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 her doctors would stay with the plan. Many of her friends had the same plan. XYZ even lobbied for senior citizens in Washington DC, and came to Mary's senior groups to explain what they were doing in support of senior citizens. And now this.
Mary's primary doctor, whom she has established a good relationship with over the last few years, "knows" her and "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!
She re-read the letter to make sure she understood the words. "He will no longer be participating member of XYZ's Healthcare Plan." She had read the words exactly right in the letter. The doctor was no longer participating; he had dropped out of XYZ.
Like many other senior citizens, Mary Spivak did all the right things before signing up. She made sure her doctors and specialists were on the Plan's list. She made sure the plan was going to cover her monthly medications and that the copays were low for any surgeries, therapies and specialist visits she might need on a routine basis in the future.
Example: When AARP UnitedHealthcare Dropped Your Doctor From Their Provider List
Please do not copy this article. It is not free to take just because it is on the internet.
Note from Rachael O'Halloran
AARP is an example only to correlate with awordlover's story of Mary Spivak. For those with a sharp eye, the dates of the YouTube videos are well after the date this hub was published but the information matches awordlover's scenario.
Update November 2, 2013 by Rachael O'Halloran:
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 President Obama as the scapegoat by citing Obamacare to be behind 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 hub 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.
Paying the bills
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 knowing that somewhere along the line, the insurance plans will pay them enough to be able to stay in business.
Mary's Consultation (i.e.Confrontation) With Her Doctor
Mary told her best friend that it was a good thing she had an appointment the next day because if she had to wait a week to talk to the doctor, she would really need serious health care treatment.
She was loaded for bear when she got to his office. When her doctor came in to the exam room, she got up and waved her letter in his face, filled with so much anger and frustration that he would do this to her.
Mary said, "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?"
Claims = Insurance company changes
The Letter, Explained
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 was not 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 and it has shown 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 medical care. That is how they keep their costs low and save money. They are banking on collecting 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 have is not something bigger. I just got two referrals from you last month to specialists for my heart 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 less patients I have with their plan, the less they pay me per patient. They try to get a package deal if we have a lot of patients on their plan, paying less per patient for a lot more patients.
"What you don't know is that I only get paid a small amount for each one. That's why I can't spend 20 minutes in each room. I have to keep moving, so I can see at least 5 to 6 patients per hour because 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."
"They are punishing you?"
"That is exactly what they are doing. We establish good relationships with our patients, our patients grow to like us and trust us to give good care. And, the Plan doesn't take into account all the people we treat who have no medical insurance. We can afford to treat them for free because we know we'll be paid for all the other patients under our care, the "sick" patients. It's not fair to us and it's not fair to the patient to disrupt their care, to assign them 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 that 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 who I have to refer my patients to on their Plan."
Mary said, "When I signed up, I was told my quality of care would not be changed. If I lose you, it will be changed! They lied to me! I go do all that work checking coverage between insurance plans and 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 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. We just have to get the word out.
"Instead of choosing a doctor from the Healthcare Plan'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 three plans have the most patients so that it is less likely that Plan will drop the doctor for lack of participation. The office manager will be allowed to give you an estimate. If he/she won't tell you, ask your doctor.
"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 going to take a little more work. She needed to call in some of her friends to cover more ground more quickly.
Get A List From The Doctor, Check The Coverages, Then Choose From The List
Drop The Plan, Not The Doctor
Mary Spivak, like many senior citizens, belonged to several senior citizen groups in her city, a church with a big congregation, plus a Bible study group. She had lots of connections with elderly people, who were the insurance company's target audience.
She got together with a couple of her friends who received letters too and they decided to go speak at each neighborhood senior center and church group. She was surprised at one of her seniors centers how disgruntled people were when they got letters from insurance companies, other than XYZ . She couldn't wait to talk to them.
When all the announcements were concluded, Mary read XYZ Healthcare's letter and said,
"You don't have to accept the letter from your insurance company dictating who will be your doctor and what kind of care you get.
"Now, because insurance companies are dropping our favorite doctors from their Plan, it is time to understand that we can choose to keep our doctor, and get rid of the insurance company. And here's how ...."
As she explained the solution, many heads nodded and most seemed to agree.
"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."
She thought it was kind of poetic justice to beat the insurance company at their own game.
Mary called her doctor, "When the chips were down, patients saw 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."
Network To Explain The Options
Speak Up! What Do You Think?
Do you think your insurance company should kick doctors out of their Plan for providing quality care which involves ordering expensive services?
Another Way To Choose A Medicare Supplement Insurance Plan (not an endorsement)
"Without Cause" Works Both Ways
So When You Receive A Letter From Your Health Insurance Plan
Consider the following:
- If you have a doctor you like (love), make every effort to keep him by choosing a Healthcare Plan which he accepts and has had good results with. Don't let your present Plan have more leverage over you by telling you that you have to accept their physician choice for you. Choose an insurance company from your doctor's list OR choose a new doctor from their provider list.
- You have many choices in health insurance companies, just like you do with doctors. Remember: You can't talk to an insurance company. You can talk to your doctor.
- For first timers, if you have not chosen a plan or a doctor yet, pick a plan that suits your needs and enroll. After a short time with the first primary doctor on the plan, switch your primary care provider to another within the plan. Do this at least twice in the first year so you can gauge the quality of care and make an informed decision before choosing a permanent primary care physician. Most Plans don't have a restriction on how many times you can change your primary choice.
- Keep an eye on the payments your Plan makes on your behalf and how much you have to contribute to the cost.
- Talk to other patients in the waiting room. You'd be surprised at 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 its coverage is suitable to you.
- Usually something changes each year -- copays, level of care, plan coverage, doctor participation. It is a good idea to keep up to date on what the new plans are offering by taking a look on their websites each enrollment period. That way you will know if your Healthcare Plan is a good fit for you.
Thank you for not copying this hub.
What Is Your Decision?
If you receive a letter from your insurance company like Mary Spivak did and like her doctor did, what will be your decision?
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 awordlover
November 2, 2013 - This hub has been edited to replace videos. Text updated by Rachael O'Halloran. This hub retains awordlover's copyright.
May 19, 2014 - Edited to remove broken links.
© 2013 awordlover