Nexus and Insurance Providers
One of the most common questions I get is how insurance works with a DPC practice like mine. Many people don’t realize that they can have insurance coverage from any insurance provider (Anthem, Blue Cross Blue Shield, UnitedHealthcare, Aetna, Cigna, Medicare, Medicaid, etc.), and still see me as their physician.
The short answer: It’s fine for you to have insurance, and in fact most of my patients do.
How It Works
When you have insurance, your plan creates a network of providers. This means they have contracted agreements with providers to pay them agreed-upon amounts for providing certain services (designated as billing codes). “Providers” in this case means doctors, hospitals, home health agencies, ambulance service, lab companies — anyone who you might visit for your health care.
My office doesn’t participate in any insurance networks. We are not on contract with any insurance company, and there are lots of good reasons for that, including being able to have appointments with you that are longer than 15 or 30 minutes (per contracted insurance billing codes). But the long and short of it is that I don’t bill insurance companies, and I don’t collect money from them either. It’s a primary care relationship between the doctor and the patient without anyone in the middle to affect care — we work for you, not insurance companies.
Ways Your Insurance Is Still Useful to You
However, the labs that I use (like Labcorp) and the imaging centers I send people to for x-rays do participate in those networks. When you have an order from me to get something done with them, you will take your insurance card with you and show it to them. They will bill the insurance company, and your insurance plan will cover the service and pay like normal.
Pharmacies also participate in insurance networks. When I send a prescription to a pharmacy, your insurance will kick in and cover your medication.
When I send a patient to a specialist, or one of my patients is admitted to a hospital, insurance kicks in as well. Those places all have their own billing folks that send the right paperwork to the insurance company so that they get paid, and your insurance covers those costs like normal.
There is One Exception
If you have an HMO health plan, your insurance company requires you to see a primary care doctor that is in their provider network. Only that doctor can send a referral out for a specialty consult or order labwork. If you have an HMO, your insurance will not cover the things that I order.
Luckily, here in Missouri, HMO plans are very unusual. In other parts of the country, HMO plans are a lot more prominent. The most famous one is Kaiser Permanente, a health plan in California that is nearly a hundred years old. They operate in a few other states also, but not Missouri.
The Bottom Line
If you have insurance, I’m glad to see you. While we won’t bill your insurance, the other providers you see can. And remember, when you see me, there’s never a copay, coinsurance, or any per-visit fee. Your monthly subscription covers all of that!