If I go to dr. who is in my network

Posted: Fri Jun 18, 2010 09:50 am Post Subject:

I'm not quite sure of what you meant by "ded to meet". Whether it's 75/25 will depend on your policy clauses.

Posted: Fri Jun 18, 2010 11:00 am Post Subject:

does the ins. pay the 75.00 to the dr. and I am only out the 25.00

Posted: Mon Jun 21, 2010 09:36 pm Post Subject:

Sounds like you have a $25 dollar co-pay when seeing your doctor.

Posted: Tue Jun 22, 2010 01:02 am Post Subject:

Is your coverage HMO or PPO?

If you are "in network" in a PPO, you may or may not have to pay a deductible, so your $25 copay might be the most you will be required to pay (if your coverage is with Anthem Blue Cross of California, you may be required to contact them by phone prior to visiting the doctor in order not to have to pay a higher copay -- I don't know of any other company with such a ridiculous rule). If you have a deductible, that comes off the top of any other billed amount after your copay, and is your out of pocket expense until fully satisfied. Your policy or insurance company will explain how the deductible, if any, works.

If you have coverage through an HMO, there should be no discussion of deductible at all -- in or out of network. You cannot go outside the network in an HMO unless it is an emergency, or unless the HMO refers you out of network. If you go out of network on your own, other than in an emergency, the whole bill will be your out of pocket expense.

Posted: Sat Nov 13, 2010 05:11 pm Post Subject:

so max, what do you mean there is a network in a ppo?

Posted: Sat Nov 13, 2010 05:34 pm Post Subject:

so in an insurance policy let's say hmo's, pos's, or ppo's there are providers in those policies and those are policies insurance companies have and supply patients with, and the insurance company has or uses these providers in their hmo ppo or pos policies to provide services to people who need services? also, providers are or can be within/under these policies as preferred or participating providers right? for example, let's take a blue cross policy..let's say blue cross offers an hmo and within that hmo there is me, mr. peters who is a doctor in blue cross's hmo policy..let's say a patient has this blue cross hmo policy and blue cross sees i am under their hmo policy, they can see i am in their hmo network and send the patient to me right?
i would just be one of many providers blue cross could or does have in their hmo network right?

Posted: Sun Nov 14, 2010 04:37 am Post Subject:

HMOs and PPOs both operate with networks of physicians and hospitals that contract to provide covered services at prenegotiated rates. Contracted physicians in an HMO receive "capitation" -- a monthly payment for each person who enrolls in his practice, whether the patient sees the physician or not. PPO physicians are only compensated on a fee for service basis only when they actually see a patient. In either system, the patient usually makes a copayment (copay) every time they see the physician.

When a person subscribes to an HMO or a PPO, they receive covered services "in-network" at the lowest possible price. HMOs historically have not charged deductibles, but that has been changing in the past couple of years, as a way to increase profits. PPOs normally have a deductible that must be satisfied before most expenses are covered.

HMOs do not allow subscribers to go outside the network (other than in an emergency) without prior approval of the HMO. PPO subscribers may choose to use any provider of their choice in- or out-of-network, but if they go outside the network, they will have higher out of pocket expenses, possibly including a higher deductible.

HMO and PPO networks may have hundreds or thousands of providers in their networks, and it is not unusual to find the same physicians in both types of plans. If an HMO physician only sees HMO patients, and does not see non-HMO patients or cash patients, his practice is known as a "closed panel". When an HMO physician sees patients other than HMO subscribers, his practice is called and "open panel". HMO physicians in a major metropolitan area may have hundreds of patients enrolled in their offices, yet see only several dozen of them in any one month.

In lieu of capitation, PPO physicians receive a higher level of compensation than HMO physicians when they see a patient.

Posted: Sun Nov 14, 2010 01:56 pm Post Subject:

so it sounds like the hmos and ppos are the insurance companies that have these hmo and ppo networks of providers right?

Posted: Sun Nov 14, 2010 03:51 pm Post Subject:

Yes. It's the company that creates the network. Originally, PPO networks were created by the doctors/hospitals to compete with the HMOs -- offering the advantage of more freedom of choice. But they were quickly overrun by the same companies offering the HMO plans -- doctors really don't know that much about running an insurance plan . . . they went to school to learn to take care of people instead.

There are, however, several HMO/PPO organizations that are "physician-owned". Doesn't necessarily mean they are better or have lower costs, but their motivations for being in business may be a bit different. Nevertheless, they are in business for the same reason as any other insurance company . . . to make money.

Posted: Sun Nov 14, 2010 05:07 pm Post Subject:

ok cool..so i think i am getting it.so the insurance company is the hmo or the ppo and they have their networks..yea i would call the insurance companies healthfirst and elderplan and verify the insurances and not know what they were referrring to when they said they were a medicare replacement hmo. so as a medicare replacement hmo they replace medicare, become primary, and are the hmo and offer hmo policies with providers that follow the hmo guidelines right? And so the providers, doctors, dme providers, etc have the contract with the insurance company to follow the hmo guidelines, and contract with the hmo to provide the services the hmo outlined? and for example even if blue cross has a mediblue hmo or a regular hmo, it doesn't matter what they call themselves whether mediblue hmo or regular hmo or whether they have these two types of policies as long as they stay properly an hmo right? the only difference in what they call themselves is what is outlined in the type of hmo they are (regular or mediblue) right?


i hope this is right..crossing my fingers..