Trap: In Network or Accepting Medicare - check directly with provider's office. (Updated Nov 7, 2022.)
Call the provider's office -- doctor, hospital, etc. -- to verify that they are currently in a specific network or that they currently accept Medicare.
Many members report being caught this way.
If a physician, determine if the doctor is accepting new patients.
If a physician, does the doctor charge a monthly or annual "concierge" or "membership" charge. This may not show up on the doctor's website or on list of in-network providers for your plan. (More info from HPAA members: https://www.hpalumni.org/health-concierge )
As one member put it: "For every Medicare Advantage PPO plan, the out of network providers have to accept the plan or you may have to pay the full ride."
The online databases are not the final word:
- Doctors have multiple affiliations. One member reported: "Prior to my medical visit, I checked to see if this physician was in network and she was BUT as it turned out, NOT in the location where I went for treatment. I discovered this when I only received a portion of the amount of the reimbursement I expected..."
- Databases have errors -- for example a provider entered under a variation in spelling or different form of the business name.
- Business arrangements in the health industry change from year to year. (For example... "As of Nov 4, 2022, the Sutter Health website -- including Palo Alto Medical Foundation -- indicates doctors that are accepting new patients under Medicare plans, when the PAMF Registrar's Office says that is not the case. It appears that Sutter negotiations with Medicare have broken down.")
Call. Talk to someone in the admin side of the provider's office.
If possible, see if you can reach a person who spends their workday prying payments out of health plans and insurance companies. (BTW, That person's choice of words or tone of voice can tell you a lot about the health plan or insurance company in question.)
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