Who should I contact? I need help from policy experts... [View all]

Today it was confirmed by my insurance company that they have only one way of knowing if a doctor or facility is in network and that is if the doctor or facility confirms that they are. If a doctor decides to drop your insurance plan, the doctor must notify the insurance company. Otherwise, they stay on the in-network provider list indefinitely; the same list used by your insurance company. Yes, the patient can call and ask if the doctor is in network. But what happens if they say yes they are and then send in a claim and the insurance company says they are out of network? The patient has to pay as out of network.

What happens if the doctor gets an authorization from the insurance company with approved services but then the claim is shown to be out of network and denied? The patient has to spend hours on the phone trying to figure out why.

When you select a plan at healthcare.gov, they encourage you to research the doctors you want to see or the medications you may be taking to see if those things are in network. But you are looking at a website that may be completely out of date. You can call the insurance company and they are looking at the same website you are so they say yes it's in network and send you an ID card with that doctor's name on it. You can then call the doctor and they may or may not be in network. You can also do the reverse; call doctor and they say yes, but insurance company says no. One doctor's office said oh you need to call your insurance company to make sure. Endless loop of nobody able to confirm.

Today a very patient rep from the insurance company explained that they are frustrated as well and have the same discussion at every staff meeting. There is no one at the company who can confirm if the doctor is actually in network or not. I was put on 2 conference calls, one with the facility where my care took place with both the billing person AND the doctor and the insurance rep told them they would have to use the provider portal to confirm they are in network. Second call was to the overall billing company and we were put on hold and then disconnected.

Meanwhile I was looking at MY personal insurance portal. I could see the doctor's name and facility listed as on my care team. I could see that they were listed as in network. The insurance agent could not see that. So I asked how it would be possible for the doctor's name to be on my personal page if someone at the insurance company had not put that person's name on there? I mean, if I went down the street to the local voodoo doctor, would THEY also be listed on the care team?

What am I missing? Why isn't there a way to know if a doctor is in your plan or not?