A woman on the phone while a doctor waits next to her

Doctor Versus Insurance Company: Patient Put in the Middle

Last updated: October 2022

Finding a doctor you like is important. Finding insurance coverage that consistently provides for your needs is important. Being able to set and forget these things is priceless.

The start of my MS insurance issues

Earlier this summer I received an email from my neurologist's office about an insurance problem. Uh oh, that can’t be good. Upon first reading, my thought was: “What the heck am I supposed to do?”

The message was regarding reimbursement rate negotiations between the doctors’ office and the insurance company. Negotiations were not going well apparently. As a result, my doctor asked his patients to contact their human resources department at work (I am my own HR department) or state legislators, to ask them to put pressure on the insurance company. Basically, asking the patients to get in the middle.

My current insurance

One reason I like my insurance policy — the same policy I’ve had for over 20 years — is that all my chosen doctors are “in-network” as part of a preferred provider organization (PPO). What this means for me is that the insurance company negotiates an allowed charge for a service and I’m only responsible for a set copay amount or 10% co-insurance payment.

The conflict between my doctor and the insurance company

That allowed charge is what is at the heart of the conflict between my neurologist and the insurance company. The neurologist’s office says that the rate is not high enough. If the insurance company won’t increase the rate, then the doctor’s office will withdraw from the PPO.

The physicians and insurance company continue to play chicken. Yesterday, I received an updated letter from the neurologist’s office stating that they indeed plan to withdraw from the PPO before the end of the year and will no longer accept my insurance. It was suggested that this information was being shared now so that patients could keep this in mind as they begin to shop for insurance plans during open enrollment season.

Evaluating my insurance options

As mentioned above, I’ve had this same policy for over 20 years. It is a “grandfathered” individual policy that costs me a lot, but not nearly as much as it would cost if I were to purchase a similar PPO plan on the “marketplace.” With my current monthly premium and annual maximum out-of-pocket limit, I am guaranteed to pay about $20,000 each year on covered medical expenses. The only way to reduce the cost would be to switch to an HMO which means none of my doctors would be covered.

Every year, I just accept that the first $20,000 I earn is set aside for medical costs. I’ll reiterate that I like my plan and REALLY like that my preferred doctors and IV therapy are covered. If for some reason I had to shop for a similar policy on the marketplace with the same company, it would cost me about $30,000.

Basically, I can’t afford to shop the marketplace. So, I need to decide if I should shop around for a new neurologist who will continue to participate with my insurance company. Or, just accept that it will cost me much more than $25 per visit to see my doctor.

The additional worry

I don’t like being confronted with issues such as this. Now I’m worrying: What if my other doctors decide to stop working with my insurance company? What if I need to change insurance because I move out of the area? How much would it cost?

Enough! Time to stop catastrophizing.

What about you, dear readers: Have you ever had a doctor ask you to lobby your insurance company to increase reimbursement rates?

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