It should be easy to figure out whether your doctor takes your insurance. But as everyone knows, it rarely is.
Your doctor is either in-network (meaning they take your insurance based on in-network pricing), or they don’t (meaning they will charge you full price, which counts against your out-of-network deductible, which you are unlikely to reach under most circumstances). If you have an HMO plan, it’s even simpler: either you see a doctor in your HMO and get in-network benefits, or you pay out of your own pocket. HMOs and EPOs don’t have out-of-network benefits – only PPOs do.
[NOTE: In this article, I’m using the term “doctor” as a catch-all for all medical service providers. The same guidelines apply if you need to know if a particular hospital, blood lab or testing facility takes your insurance]
Here’s a translation of some healthcare-speak: “In-network” means that your doctor is contracted with your insurance company to provide services at an agreed-upon price (sometimes they are called “participating providers”). “Out-of-network” means they are not. An HMO plan limits your access, and your coverage, only to doctors that are in the HMO’s contractual network. A PPO essentially does the same thing, with two differences: a PPO allows you to make an appointment directly with a specialist, rather than having to get a referral from your primary care doctor, and it pays out-of-network benefits after you spend a lot of money out of network. An EPO is like a PPO in that you can go directly to specialists, but like an HMO in that it offers no out-of-network coverage.
Finding out whether your preferred doctor takes your insurance is where the problem lies
Doctors’ offices should have big menu boards, like fast-food joints, saying exactly which plans they take for in-network PPO or HMO benefits. I’ve never seen one.
At best, the receptionist will know the answer (which is rare), or there will be a helpful person in the billing department who can give you a clear answer. At worst, you will walk into a doctor’s office thinking they take your insurance, no one will tell you that they don’t, and you’ll get hit with a big, surprising bill that you are obligated to pay. I have a client who got a $1,300 bill for a routine pediatric visit because their pediatrician had stopped taking their insurance and didn’t tell them.
Below you will find resources to help you find out if your doctor takes your insurance. Since I am a Northern California-based insurance broker, these links are for local providers. But if you are elsewhere, you can look for the same information in your area. I’m about to explain how.
How to figure out if your doctor takes your insurance
Almost all doctors’ offices are now part of large medical groups that handle their administrative functions, including which insurance companies they contract with. Some groups, such as Palo Alto Medical Foundation, do an excellent job of posting all the plans they take, and updating the page frequently. That’s really the gold standard, but I’ve never come across a page as thorough as that one. Stanford Health does a pretty good job with its page, but it’s not as comprehensive as it should be. Brown & Toland does a terrible job – you have to search their FAQs to find the page, and then when you click, it takes you to the wrong page!
The first thing you need to know is what kind of insurance you have. Most people have either employer-sponsored insurance (aka “group insurance”) or personal insurance for themselves or their family (aka “individual” plans or simply “Covered California”). In California, some government employees have coverage through CalPERS. Military personnel, except veterans, have coverage through TriCare.
If you are on Medicaid (known as Medi-Cal in California), you have a particular type of insurance that in California varies by county, and you must find out if your doctor takes that exact insurance plan. Those on Medicare also need to be sure that their doctors take their exact type of insurance. Stanford has a good page explaining the different types of Medicare coverage they take – but if you are not a Stanford patient, use this information only to help you to learn what questions you need to ask your provider.
In general, more doctors take group health insurance than individual health insurance. That’s simply because group health insurance pays them more than individual insurance, and some doctors don’t want to accept the lower compensation. The reason this happens has to do with how insurance pools work, but the bottom line is that insurance companies can afford to pay more out of group insurance pools than individual pools, which are separate.
This leads to a big misconception about health insurance – that if a doctor “takes Blue Shield” that they take ALL Blue Shield plans, and that may not be true. Imagine if you had to ask at the supermarket whether they took your particular version of Visa or Mastercard, and if not, you’d be forced to pay cash. That’s what we’re dealing with in health insurance.
So when you are not 100% sure your doctor takes your insurance, here’s the information you need:
- The exact name of your plan, and whether it is an HMO, PPO or EPO network
- Whether you have group, individual or another type of coverage
- Your policyholder ID number, commonly called a “member ID number” or something similar. These numbers are coded to provide billing offices with information about the type of plan you have.
- The federal tax ID number of the doctor’s office. Yes, you actually need that number. That’s the coin of the realm in health insurance. It’s how the insurance companies know whether they pay in-network claims from a particular doctor. Yes, you can ask the doctor’s office for that number and they should be able to provide it.
Next, you need to know what medical group your doctor belongs to. In the Bay Area, some of the biggest are Sutter Health, Stanford Health, Brown & Toland, Dignity Health and Palo Alto Medical Foundation. Search Google for your doctor’s name and you’ll often be able to find this information. If it’s not perfectly obvious from an Internet search, you must call your doctor’s office and ask them, and ask about which insurance plans they take. There are still some freestanding doctors offices that are not part of a larger medical group, so you have to be extra careful to ask the right questions of their front desk people before you use their services.
Once you know which medical group your doctor belongs to, you can go to that group’s website and look for their insurance page (Some doctor’s offices have such a page on their own websites, but they are often woefully incomplete). If you do not get a satisfactory answer from the web page, call the doctor’s office and/or the group’s main office. But be prepared to come away without a definitive answer.
The next place to turn is your own insurance company. Call their customer service line, give them your policyholder information and the exact name of the doctor, and get them to tell you whether they are in-network for your plan. This usually results in a satisfactory answer, but needless to say, this can be time-consuming. Some insurance companies have provider directories on their websites as well, but you usually have to be logged in as a policyholder to access them. My only personal experience is with the Blue Shield of California website, and it’s good for simple searches, but I don’t rely on it as a definitive resource, because there’s no telling how recently this information was updated.
Here are the insurance pages of major Bay Area medical groups:
- Sutter Health
- Stanford Health
- Palo Alto Medical Foundation
- Brown & Toland
- Dignity Health
- Dignity Health operates in several states and across Northern California, and they don’t provide a way to just go to their main website and search for insurance plans. The best way to do the research is to type dignity health insurance accepted into Google and you will see a list. (Or just click on the link in the prior sentence)
- Verity Medical Foundation
- Physicians Medical Group of San Jose
- John Muir Health
- Marin Healthcare District
I’d be very interested to hear about your experiences figuring out if your doctor takes your insurance.