Always or Never Verify PCP Network Participation

[WCMason]

Two MA certs knocked out today. With one carrier instructions were to always confirm PCP is in network by calling the doctor's office. With the other instructions were to use carrier's online provider directory and NEVER call the provider (emphasis theirs). Reason given for not calling is that doctor offices often give incorrect information. While true, carrier directories are pretty bad, too. Crazy.

 

[Mink]

Two MA certs knocked out today. With one carrier instructions were to always confirm PCP is in network by calling the doctor's office. With the other instructions were to use carrier's online provider directory and NEVER call the provider (emphasis theirs). Reason given for not calling is that doctor offices often give incorrect information. While true, carrier directories are pretty bad, too. Crazy.

suggest the client do it to confirm.

 

[AllGold]

I tend to go with the second (don't call) because I have talked to office staff who say things like "Oh, we take all insurance" and that is their only answer when the reality is they do not.

The person who actually handles the billing is the only one who would know for sure and it's often difficult to reach them.

Plus, the doctor's office staff may say and think they take Humana (just as an example) when in fact they accept the <65 individual products but not MAPD.

 

[Bob_The_Insurance_Guy]

Leaving a message for the Billing Department:

Hi, this is Bob Levine, and I am an insurance agent, working with a patient of yours, Joe Smith. We are trying to locate a Medicare Advantage Plan that he can use, and still see Dr. Jackson. Can you check and make sure you guys work with Humana Gold HMO, here in Atlanta? Thanks.

 

[policy doctor]

Before I get to clients home, I tell them to call their doctors to verify that they take the plan interested in. I also tell them that if a doctor's office say's no,ask what other companies medicare advantage plans they take. It might be one I represent also.

 

[russelltw]

I ran into a situation this year. Client's PCP was in the network, but was bought out by a group that was not in the network. PCP is no longer in the network. Client was not happy, but understood.

 

[taterpeeler]

Leaving a message for the Billing Department:

Hi, this is Bob Levine, and I am an insurance agent, working with a patient of yours, Joe Smith. We are trying to locate a Medicare Advantage Plan that he can use, and still see Dr. Jackson. Can you check and make sure you guys work with Humana Gold HMO, here in Atlanta? Thanks.

And my friend you just got fined for hippa violations... Just my view on the law but I still feel you screwed up.. Never leave a mesg with the client name

 

[Chazm]

Yeah I wouldn't see the purpose of leaving the clients name.

 

[yogooglethis]

And my friend you just got fined for hippa violations... Just my view on the law but I still feel you screwed up.. Never leave a mesg with the client name

I believe you are right on that.

A situation I have had happen many times is where I am calling the PCP office on behalf of the client to determine if that doctor will accept an existing patients on XYZ PPO MA plan on an out of network basis and many times the office manager ask me the patients name before they want to give me the answer.One it shouldn't matter and two it's a HIPPA violation for me and the doctor.

To the OPs questions I know that you can get a complaint with UHC if even after doing all your due diligence to make sure a provider is in the network ( directory,calling,online etc) and it turns out there not actually contracted.It sucks because often the most unreliable source is the girl answering the phone at the doctors office.

I am very familiar with the network on the PPO plan i use 95% of the time but every once in a while i run in to a situation where even though the directory,online search and doctor's office confirm provider is contracted I still have some doubt I will call the doctors office with my client either on a 3 way or speaker phone and let the client here it from doctors office directly.This way if the doctor really isn't contracted the client is much less likely to make a complaint on agent.

 

[Chazm]

I believe you are right on that.

A situation I have had happen many times is where I am calling the PCP office on behalf of the client to determine if that doctor will accept an existing patients on XYZ PPO MA plan on an out of network basis and many times the office manager ask me the patients name before they want to give me the answer.One it shouldn't matter and two it's a HIPPA violation for me and the doctor.

To the OPs questions I know that you can get a complaint with UHC if even after doing all your due diligence to make sure a provider is in the network ( directory,calling,online etc) and it turns out there not actually contracted.It sucks because often the most unreliable source is the girl answering the phone at the doctors office.

I am very familiar with the network on the PPO plan i use 95% of the time but every once in a while i run in to a situation where even though the directory,online search and doctor's office confirm provider is contracted I still have some doubt I will call the doctors office with my client either on a 3 way or speaker phone and let the client here it from doctors office directly.This way if the doctor really isn't contracted the client is much less likely to make a complaint on agent.

That's completely opposite for me. I call all the time and I can't think of one office that has asked the clients name. If they did I would say it doesn't matter