Historically speaking, seeing and paying for a doctor’s services were relatively simple. You either saw the doctor and paid the bill or you had an insurance plan that let you see the doctor you wanted to see and paid all or part of the bill. Now, medicine is laden with managed care health insurance plans, which now dominate the way we pay for healthcare.
Managed care in healthcare is a complicated experience. There are several types of managed care programs, including a type that exists where you must see your primary care doctor for a referral if you want to see a specialist and programs where you must see a doctor that is “in network” in order for the insurance plan to authorize payment for the services you receive.
If you receive services from an “out of network provider” you will have to pay for it yourself.
Managed care was developed over the last forty years in response to the fact that healthcare costs were soaring. Doctors were charging whatever they wanted, knowing that conventional insurance companies would be obligated to pay the bill. With managed care, doctors sometimes must agree to see their patients at a reduced fee in order to save costs and most managed care programs do not pay full price for the doctor’s or hospital’s services.
But before you go about signing up for a managed care healthcare program, there are a few things it helps to know. For example, you need to know if your managed care plan restricts the specific doctors you can see. This is the “in network” idea already discussed. Technically, you could have been seeing the same doctor for many years only to find out that your doctor is not “in network” and you would have to pay out of pocket for his or her services. Specialists allowable under your plan may be too far away for you to get there to see them.
Secondly, different managed care programs have different payment plans. Some will ask you to put up a copay to see a doctor or even to go to an emergency room. You may have to pay up to $70 up front to see an emergency room doctor, regardless of your emergency, in order to have the insurance plan pay the rest. For family practice doctors and internists, copays are more reasonable and can be as little as a few dollars.
Thirdly, managed care health plans often restrict the kind of services you can get. You may not be able to see an eye doctor under your insurance plan or you may not be able to receive home healthcare services if you should become ill and need some kind of home care. Managed care plans have booklets that list the services that are acceptable; however, most people don’t read them until they actually become ill.
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