Knock-Knock–Is there a Doctor in the House?

A federal employee of 18 years, the author recently used an out of network doctor for a family member “because there were not any in network doctors available at the medical center we selected” even though the facility as a network hospital. The result was that, despite having insurance, the out of pocket expenses were significant. The article was written to that others could benefit from his experience and to encourage federal employees to research and carefully consider options when choosing a medical insurance provider.

By Don Richards
Language Arts Instructor
US Forest Service/Job Corps

Do you know which government subsidized insurance company has network providers in your area?

Another open season has passed for government employees to secure one of the best possible insurance plans available in the world. That is, if you play the game called, "Is there a Doctor in the House?"

Several government insurance companies do not have adequate coverage of network providers across the nation. Certain companies only have limited coverage in some geographical areas of the United States. They lack providers in many specialty services that are required for those of us who are advancing in age such as in urology, cardiology and oncology. For instance, there may be only podiatrists on the rolls.

Never count on your insurance company to have network doctors in your area! Some companies aggressively recruit doctors while others do not. Insurance companies may pay substantially lower rates to out of network doctors.

Furthermore, don’t ever try to use an out of network doctor when there are no other network doctors available and expect your insurance to treat them as an in network provider, particularly when it comes to paying them. There are so many clauses and underlying meanings in their policies that one representative told me to pay very close attention to the gray areas. My response was "You mean– I should read between the lines?"

Representatives also convey to their policyholders that if you disagree with their policy you can always write a formal appeal to the company, which will most likely be denied, in which you will have to appeal to the next level with the Office of Personnel and Management. Finally, the policy reads that if you still don’t agree with OPM you can file a lawsuit. That is what every policyholder wants to hear when he or she is just seeking fair and adequate medical coverage.

What should a patient do when he or she is being rolled into the operating room from a life threatening circumstance and there are no in network doctors there or the hospital is not in the network. I can hear myself yelling, "Hold everything! Are there any network doctors in the house? Is this a network hospital?" Remember an in network hospital doesn’t necessary mean that there are in network doctors working there.

The bottom line is that it is your responsibility to find out about your insurance! If you don’t use network doctors or are unable to, you may be losing the benefits of lower costs that are associated with them. It would be well worth your time to investigate the availability of in network doctors in your geographical location who you could foresee using in the future. You and Uncle Sam are paying large sums of money to these companies to utilize their services in time of need. Don’t get caught off guard by not knowing which insurance company has coverage in your area or even worse doesn’t! Don’t wait for a catastrophe to occur to find out that your insurance doesn’t have you covered as well as you should be.

One positive thing about all of this is that as a government employee you can change to a different insurance provider during open season, even with pre-existing conditions. So, I suggest to take a few minutes and find out what kind of doctors are in your area and which ones are in network doctors with your insurance. You may be surprised! Knock, Knock! Is there a Doctor in the House?


Editor’s Note: This article was submitted by a reader who wished to share his recent experience so that others would benefit. Any opinions expressed by the author represent his personal views and do not necessarily reflect those of FedSmith, Inc.