What to Do When Your Doctor Leaves Your Health Plan

When you have a good relationship with your doctor, it’s almost like magic — especially if you’ve ever had a doctor you’ve disliked. After all, a good doctor-patient relationship can do wonders for the quality of your health care. You’re more likely to be open and candid, and the doctor is more likely to listen closely and provide better care. And if you’ve been seeing the same doctor for years, they know your medical history inside and out.

That’s why it can be so disappointing to find that your doctor is no longer in-network, meaning your health insurance company no longer covers your visits, or covers much less of the bill. Although most people would love to stick with a trusted provider, out-of-network doctors’ fees are often too steep to pay out of pocket.

But for many who are insured through an employer or spouse’s employer, you can’t switch to an insurance policy that does cover your doctor until open enrollment later in the year. That is, unless your employer plan offers mid-year changes (which is very rare) or you experience certain life events such as marriage, divorce or a new job.

Other reasons can force you to cut ties with your doctor: Your employer drops your current plan, or your doctor retires or leaves the practice.

As Trisha Torrey, a patient empowerment and patient advocacy pioneer, and founder and former director of the Alliance of Professional Health Advocates, sees it, patients essentially have three main options when a doctor leaves their health plan. You could:

— Change health plans, when you’re able to do so, to one that your doctor participates in if such coverage is available. However, it may not be among the plans you have to pick from, like those offered by an employer.

— Negotiate a cash price to continue seeing your doctor. The willingness of a doctor’s office to do this, the cost and what’s affordable for each individual will vary considerably.

— Set about finding a new doctor.

Sometimes, entire health systems and insurance networks part ways when they can’t reach an agreement over issues like physician reimbursement. “It’s something that definitely does happen, fortunately not as frequently as imagined,” says Dr. Sterling N. Ransone Jr., a family physician in Deltaville, Virginia, and president of the American Academy of Family Physicians.

[Find: The Doctor That Is the Right Fit for You.]

When Your Doctor Leaves the Practice

It’s not unusual for doctors to enter and leave health insurance networks, or move to a different location or workplace.

When your doctor does drop out of your network, you’ll probably be warned. That means you might get a nice letter in the mail informing you of an upcoming change — or a bill after services are rendered for an amount way higher than your normal copay or insurance.

Physician turnover is not uncommon. On average, primary care and multispecialty practices experienced slightly more than 10% turnover in a 2021 survey, according to the Medical Group Management Association, which consists of 15,000 group medical practices representing more than 350,000 physicians. Surgical single specialties had more than 9% physician turnover, while nonsurgical single specialties had a slightly less than 6.5% turnover.

When physicians leave a health plan, it’s often because they’re changing jobs or employers, but it can also happen that a practice chooses not to accept a plan any longer, particularly with smaller plans, according to MGMA. If that happens, the best strategy is for patients to go to the health plan for a list of in-network providers that are accepting new patients and start there, the association advises. Then start looking at provider reviews as well as asking for recommendations and referrals to narrow down who you want to consider switching to.

[Read: How to Pick a Health Insurance Plan.]

When Your Employer or Insurance Company Makes a Change

Another scenario is when options for employee health plans change or dwindle. “The more common one I see is where an employer has to make a difficult decision to go with a different company than they had before,” Ransone says. “What I’ve seen more recently is that the numbers of choices that are being offered to the patients are declining.” When employers drop an insurance company, workers may find their doctor is no longer in their network.

Insurance companies also can make business decisions that leave patients scrambling. “Some insurers will decide for a certain geographic area, they just won’t cover patients,” Ransone says. “We’ve seen that. One of the major insurers in our state decided to exclude our county. That was probably about four years ago. So, a lot of people who had that insurer, just because of geographic reasons, could no longer use that insurance company.”

Insurance issues over which patients have no control can disrupt long-held doctor-patient connections. “Patients are quite dismayed,” Ransone says, along with their health care providers. “One of the advantages of being a family physician and a primary care provider is that part of what we do is develop these long-term relationships with families. It’s like a divorce sometimes. It’s really upsetting for the patient and the physician.”

[Read: What’s Medicare Supplement Insurance?]

Easing a Physician Transition

If changing insurers, physicians or medical practices is inevitable, you and your current provider can take steps to make the best of the situation:

Seek referrals. “When I have a patient who is going to a different insurance plan, or more commonly for me, it’s something like people moving out of the area, I’ll frequently know other physicians who participate in their plan,” Ransone says. Another avenue is to check with foundations or national associations affiliated with certain chronic conditions, he adds, such as organizations focused on diabetes or rheumatoid arthritis.

Be proactive. “The first thing I always tell patients is: When this is happening and you know it’s happening, don’t delay,” Ransone says. He advises being “fairly aggressive” in speaking not only with your physician but also to good friends and members of religious or other community organizations you belong to about possible new doctors who could be a good fit.

Transfer medical records. “Getting records sent to a new physician is really important,” Ransone says. “We don’t want folks to get behind on their screenings, their vaccines and management of chronic conditions.” For instance, he says, it’s highly concerning if someone with diabetes should fall between the cracks for months before seeing a new physician. “A lot of problems can happen in that time frame in between,” he says. “So I like to make a smooth transition when we do what we call a ‘handoff’ to someone else.”

Communication between physicians. In addition to electronic information transfer, a call between your old and new doctors can be a bridge for good care management. For a patient with a challenging medical condition, Ransone says, he’ll often call to explain how they’ve dealt with it over recent years, such as: “I’ve tried this before and this is how we ended up on our current treatment regimen.”

Advocating with insurers. Even though a medication works well for you, a new insurer might not cover it. “Typically, when you go to another insurance, they’ll have their own preferred medication: ‘Nope, we’re not going to pay for that one, we want to use this one,'” Ransone says. He may write a letter to the insurer explaining: “We tried this medication three years ago, it didn’t work and that’s why we’re using the one we’re currently using.” In addition, he says, “Sometimes we can hand that information off to the next physician — it really does allow continuity of care for the patient.”

Familiarize yourself with a new practice. Introduce yourself, ask questions and find out if you mesh with potential new providers before you urgently need care. “You want to make sure that you’re comfortable with the physician you’re seeing, that you’re confident in their abilities and that they’ll be able to coordinate care,” Ransone says. Ask about the office’s accessibility, for instance, if you have mobility issues. Is public transportation available, or if you drive, can you park within a short distance?

Understand your coverage. “A lot of patients just don’t know their insurance,” Ransone says. Often, “there are provisions in there they don’t know about. Sometimes they just assume it will be the same as it’s always been — and it’s not.” His advice: “Look at your policy and make sure you know what it really covers.”

Find Out if You’re Protected

Depending upon where you live, you may be able to retain in-network-level coverage for your doctor — at least temporarily — even if he or she leaves your network. Check to see what continuity of care protections your state has in place.

“Sometimes there are absolute reasons that you can’t change to another doctor,” Ransone says. Maternity care for a high-risk pregnancy and ongoing cancer care are among the most common reasons that insurers allow some continuity of care with a previous physician.

While protections vary, under these clauses, you may be able to continue paying the same copays and fees for your care until the baby is born or a medical condition resolves, for example, before you need to find a new provider.

“You have to look at it, you have to ask about it,” Ransone says. “You don’t want to change up your oncologist in the middle of a course of chemotherapy because of an insurance provision.” He sometimes provides documentation for why someone should stay with their specialist “because we need to keep that same continuity going for the most excellent care of that patient.”

Continuity of care is also available in some insurance plans without being required by law. In these cases, patients with serious chronic conditions or terminal illnesses may also keep their providers for up to 12 months in order to make a safe switch.

Plan Enrollment and Switches

There’s good news for the roughly 28 million seniors in Medicare Advantage Plans, private alternatives to government-run Medicare: Those with these insurance policies can, under certain circumstances, leave their plans mid-year if their doctors do. There also is the Medicare Advantage Open Enrollment Period which runs from January 1 through March 31 each year. This enrollment period allows you to switch Advantage plans or go back to original Medicare. You can switch plans during the Annual Open Enrollment period for Medicare, October 15 to December 7, as well.

For others covered by private health insurance who are considering switching plans, check with both the plan and the doctor’s office to learn if your physician is in a new plan you’re considering. Of course, which health providers are covered by a particular plan and which aren’t is always subject to change. “But if you confirm from both directions, the chances are pretty good that you’re going to be OK and your doctor’s going to be covered,” Torrey says.

If it’s not possible to switch plans, you can check to see if it would be affordable in the short or long term to pay cash to continue seeing your doctor. Though typically doctors bill insurance, and that’s what patients generally expect, Torrey says it may be worth checking if you can negotiate a lower cash price with the doctor’s office to maintain continuity of care. “Oftentimes they’ll give you a really good deal to pay cash because they don’t have to bill your insurance,” she says, which may reduce a provider’s administrative costs, not to mention the added hassle of processing claims.

However, for the patient paying out-of-pocket costs can add up, particularly if you see the doctor often, and a cash arrangement may just not fit within the budget. “You have to decide whether thatdoctor is worth the cash outlay based on the numbers they give you,” and whether you can afford the negotiated rate, Torrey says.

If your workplace is mandating a change in your insurance coverage, give feedback. “Know your plan, read it and if you’re unhappy with it, talk to your employer,” Ransone says. Employers want employees to be healthy, he notes, and multiple complaints about a plan might make a difference in their coverage decisions.

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What to Do When Your Doctor Leaves Your Health Plan
originally appeared on usnews.com

Update 05/18/22: This story was published at an earlier date and has been updated with new information.

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