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Azeranth t1_j5ruj9k wrote

Your insurance has an advertised price for a procedure saying "we will pay upto X price". If the doctor thinks "well that's a fair price" then they accept the insurance. If not, they don't.

Sometimes they'll ask you to cover the difference between what insurance will pay and what the doctor charges.

These are different from co-pays, which the insurance expects you to pay before the insurance pays, meaning you pay no matter how much the insurance covers, even all of it.

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Misssheilala OP t1_j5rvn8y wrote

Thanks for explaining. Do you know if they have to inform you of this? I ask because I’ve been with the same doctor’s office for 3 years and had multiple appointments with them through those years. But today when I went it I was informed I am out of network and they asked me to sign a form acknowledging so. This has never happened at any of my in person or telehealth appointments before today.

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FSUnoles77 t1_j5rwfar wrote

Did the company you work for recently change insurance providers during their last open enrollment?

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Misssheilala OP t1_j5s3a01 wrote

Nope! My insurance has been the same for the last 3 years and I selected to keep the same coverage during our open enrollment in November. To say I was caught off guard today would be an understatement.

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Azeranth t1_j5rwbzy wrote

Generally the answer is sort of. They take your insurance information, and are not allowed to lie about being in network. That's insurance fraud and they get in big trouble.

They usually make you sign something agreeing to pay whatever insurance won't. This is sort of redundant, but you essentially are confirming that you understand that insurance may not fully cover your care. You should not have to sign this at an in network facility when undergoing non-elective care. Exceptions arise for emergency care where you sign on a blanket basis, because it's likely to overrun your premiums.

They are not legally required to tell you what the price will be and they are not legally required to honor the price advertised when they bill you. Importantly, they also can't just lie. They're bound by what's called "good faith". As long as they price they give you is honestly their best guess, they're off the hook.

Forcing medical providers, especially hospitals to publish and honor the price of their services not subject to insurance negotiation was a big part of Trumps healthcare reform initiatives, along with right to try and other misc small items.

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Misssheilala OP t1_j5s3nbn wrote

They’ve never asked me to sign anything acknowledging they were out of network until today. I would have understood if my insurance changed (it hasn’t) or if they had dropped Aetna as a provider. When I asked them if they dropped Aetna they said they have never contracted with Aetna, which now I understand is different than excepting Aetna thanks to your first comment. All very informative and I appreciate your explanation!

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rsclient t1_j5ryja2 wrote

Doctors decide (every year?) what insurance they will accept. I remember one particular year where essentially every single doctor in my area that used to take my insurance decided that the reimbursement rates (or the hassle factor) were too much and stopped taking the insurance.

My list of potential doctors went from "dozens" to "one" (and then that one doctor retired a few months later)

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