Why Can’t The Pediatrician’s Office Tell Me What Services Will Be Covered By My Health Insurance Company?

Written by Cliff Wu M.D.

Medical insurance in the United States has to be one of the most complicated and frustrating systems that a family can endure. One question that has arisen recently has been whether a clinic can tell what services are covered by a given insurance plan and whether or not our clinic is in network.

Unfortunately, the answer to both of those questions is no. We frequently do not have access to that information because of all the different insurance plans, and each plan will have different variations. For example, we can be in network for Branch A of Insurance X but not for Branch B within Insurance X and there is no way for us to tell until after we submit the bill to Insurance X. In fact, we won’t even know that there is a Branch A or a Branch B. Of course, that doesn’t help when we try to determine whether we’re in network at the appointment time.

So what’s a family to do? The only answer we have is for each family to check with their own insurance company about what benefits are offered and which clinics are in network. The insurance carriers will release a book every year with which clinics are in network; they may also post clinics and doctor names on their website. Even then, it’s not always foolproof because the carriers may or may not keep these resources up to date.

As pediatricians, we would absolutely love to be able to streamline the process for families, verify our network status, and determine the coverage and benefits, but we simply do not have access to that information, and we are just as frustrated by this process as the families that run into this problem are. Again, a family’s best bet is to check with the carrier using the policy number in hand because that is something that we cannot do until it is too late.

This piece is just a small part of American healthcare complexities. If you are interested in a bigger picture of this nightmare, Planet Money did a blog and an eye-opening podcast entitled “The Pain-In-The-Butt Index” in July 2010 that details the staggering burden that we all endure.

Dr. Wu is a practicing pediatrician in Lakeville, MN. He runs a family-oriented practice built on love for children and the desire to make them feel comfortable with healthcare. 

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