Avoid the Texas Health Insurance PPO Network Trap

Most all Texas health insurance consumers on the individual market are using plans that in some form utilize a Preferred Provider network knows as PPO’S. These networks allow the client of a Texas health insurance plan to visit a doctor and be considered as in network therefore just paying a co-pay or deductible and allowing the negotiated billing to take over. What happens if your doctor withdraws from the network, in some cases even with pending major surgery just days away?

First for a little explanation of how PPO networks work. A Texas health insurance company enters into a contract with doctors and hospitals, also known as providers. The agreement states that the providers will charge a certain price for a certain medical procedure. These discounts can amount to as much as fifty or sixty percent. The advantage to the provider is they have some semblance of a guarantee of getting their services paid from the Texas health insurance company. The advantage to the insurance company is in cost containment and control. As long as your provider is in network you have a simple co-pay or deductible to meet and the provider then bills the Texas health insurance company. Before there were PPO plans consumers were forced to pay the bill up front and file the claim on their own without much help from the provider. Clients would wait weeks before the Texas health insurance company would release payment to the client for the bill.

OK, this exact case I’m going to explain happened just a few days ago. The consumer had been visiting a doctor that at the time WAS in network. Thousands of dollars in testing had already been done and it was determined the client needed brain surgery. The doctor scheduled her brain surgery for a few weeks out. During the pre-op meetings my client was informed that her doctor no longer was a member of her PPO network, as the provider had decided to stop taking all insurance plans. Brain surgery is less than two weeks away and her provider just dropped the biggest bomb of her life. The client is now left scrambling to figure out what to do. The doctor didn’t seem to care that his client would now have to pay thousands upon thousands of additional dollars in order to have the surgery. After speaking with the insurance company it was determined that she could attempt to convince the provider to sign a continuity of care agreement, this is an agreement that for just her surgical procedure he would bill all charges as in network. He still would not budge, he held firm on his new business practice of NO INSURANCE. Cash only.

The reason I feel this story is so important is this. Most Texas health insurance agents or brokers do take the time to inquire about who your present doctors and providers are but things can change. Any time a consumer needs to have a medical procedure please ask questions, inquire about PPO network status. Before a surgery is preformed request to know who will be the anesthesiologist and confirm he is in network. Confirm that the facility or hospital is in network. So many times consumers of Texas health insurance policies just assume that if my surgeon is in network all the providers will be in network. That assumption is wrong up to fifty percent of the time in my opinion. 

When a doctor is considered out of network on a Texas health insurance PPO plan, out of network deductibles and charges apply. These amounts can add up to thousands and thousands of dollars that are unexpected. Always protect yourself, ask questions call the facility and confirm your status. Just because the providers show up in an outdated network book or on the Internet as in network means nothing. Things change and these type of changes can only do harm to the consumers of Texas health insurance policies.