Understanding and navigating the U.S. healthcare system can be challenging. This complex system can confuse even so-called healthcare experts. One of the most common questions I get in the office is whether or not I can see them as a patient if they have Medicare or some type of other insurance.
For example, patients may ask:
“Do I have to see a doctor in my health insurance network?”
“What happens if you see a doctor outside of your health insurance network?”
“Is that even allowed?”
The short answer: You do not have to see a doctor that accepts Medicare or your insurance.
Independent primary care physicians can not only care for you, but they can also refer you to specialists and facilities for diagnostic testing (labs, imaging, etc.).
I’d like to elaborate on these questions and dispel some of the myths and/or misconceptions many have when it comes to choosing a primary care physician.
First, I’d like to clarify some terminology since a lot of people confuse and/or interchange healthcare words/phrases.
“Accept” or “Take” insurance: When an organization, facility, or provider bills a third party payor (e.g. insurance, Medicare/Medicaid) for services rendered. The patient’s out-of-pocket responsibility depends on multiple factors including deductibles, co-pays, terms of the insurance plan, clinical necessity, and more.
“Coverage”: Used to describe eligible healthcare services that are billable, subject to terms, and payable by one’s insurance company. Just because something is “covered”, does NOT guarantee payment, since the ultimate decision to pay is up to the third party payor. Typically, one receives an Explanation of Benefits (EOB) with an itemized list of gross charges. These charges are adjusted based on a negotiated payment percentage between the provider and the insurance company resulting in a final amount owed to the provider by the patient. This can be a complex and non-transparent process.
“Care”: health service and/or goods, regardless of how it paid for. Physicians and other healthcare professionals provide care. Insurance does not provide care.
“Direct Care/Cash Pay”: When an individual pays out-of-pocket directly to the provider for healthcare services rendered. Otherwise known as “cash pay”. This is the simplest and most transparent transaction in healthcare. Note, most facilities are obligated to bill one’s insurance IF they are aware that said person is insured. If one does not disclose that they are insured at the time of service, then it is possible to request the cash price for a service. Direct Primary Care (DPC) is growing in popularity as an insurance-free option whereby patients pay a fixed retainer fee (usually monthly) for direct access to their physician, unlimited office and virtual visits, and access to free-market/wholes medications, labs, and imaging.
In-Network: When a provider has an agreed to accept an agreed-upon payment for services provided to a specific third party payor and their respective members. In return, the third-party payor will list that provider as a network provider.
Out-of-Network: When a provider has not agreed to receive payment for services rendered to a member of a health insurance network. If a provider has no contract with the health insurer, they are considered out of network. Most direct primary care physicians are out of network and opted out of Medicare. Out-of-network providers do not bill your insurance.
Out-of-Network Primary Care Physicians examples: Direct Primary Care (DPC) Physicians, “Cash-Only” physicians, independent PCP’s and groups not contracted with insurance, and physicians who have “opted out” of Medicare.
Opted-out of Medicare: When a provider will not take payment, nor bill Medicare for services. Patients may receive care from an opted-out provider, however neither patient, nor doctor shall submit charges for reimbursement to Medicare. Medicare beneficiaries may see an opted-out private physician. Typically the patient signs an agreement with the private physician, acknowledging that they will not submit their charges to Medicare for reimbursement.
Referral: When an provider orders an outside specialist consultation or diagnostic test (lab, x-ray, etc.). Collecting payment for the consultation and/or diagnostic test is the responsibility of the specialist or facility, not the referring provider. If your doctor is out-of-network, and refers you to an in-network or covered specialist, payment for that specialist visit administered by your insurance.
Let’s break down the different types of coverage.
- Private Insurance. Preferred Provider Organization (PPO) Health Plans (non-HMO), High-Deductible Health Plans (HDHP), Health Savings Account (HSA), and the “BUCAH’s” (Blue Cross/Blue Shield, United, Cigna, Aetna, Humana) comprise the majority of private health insurers. There are myriad affiliated offshoot insurance plans that are administered by these large insurers and as a result, each plan has their own network of providers. Providers include physicians (MD, DO), physician assistants (PA), and/or nurse practitioners (NP), representing all specialties. This is important to point out since you may find yourself being assigned to a mid-level provider (NP, or PA), not in small part due to the fact that primary care physician panels fill up quickly and may be closed to new patients.
| Private Insurance -
Referrals |
Accept In-network Providers Referrals | Accept Out-of-network Provider Referrals | Notes |
| In-network Specialists | YES | YES | |
| In-network Imaging Orders | YES | YES | |
| In-network Lab Orders | YES | YES | |
| Private Insurance - Physician | Out of pocket cost | Direct Pay Option | Notes |
| Out-of-network Primary Care Physician | Per plan terms or cash pay | YES - either fee for service or direct primary care membership | Direct Primary Care is a model of payment whereby the patient pays a membership fee in exchange comprehensive primary care services |
| Out-of-network Specialist | Per plan terms or cash pay | YES - fee for service; | Only select markets have specialty care membership models |
In-network Specialists: Accept Referral from BOTH in network providers and out of network providers.
In-network Imaging Centers: Accept Referral from BOTH in- and out-of-network providers
In-network Labs: Accept Referral from BOTH in- and out-of-network providers
Out-of-network Specialists/labs/imaging centers: may be subject to more out-of-pocket expenses depending on the circumstance.
Out of network primary physician: may be subject to more out-of-pocket expense depending on circumstance; ok to cash pay or direct pay out-of-network primary care physician (insurance is not billed for visits in favor of a monthly or other retainer membership fee -- see “direct primary care”).
- Health Maintenance Organization (HMO) and Medicare HMO/Advantage Plans. These insurance products are more of a “closed” network and as a result strongly incentivize enrollees to stay in their network by strongly penalizing those that stray from the network. The HMO manages, and thus has more control over, one’s entire healthcare experience -- from primary care to specialty and hospital care. This means less choice for the individual patient. So, if you have a doctor whom you really like, but is not affiliated with the HMO, you’ll probably have to pay 100% out of pocket.
| HMO Insurance
Referrals |
Accept In-network Providers Referrals | Accept Out-of-network Provider Referrals | Notes |
| In-network Specialists | YES | Usually | Depends on the HMO plan and individual needs |
| In-network Imaging Orders | YES | Usually | Depends on the HMO plan and individual needs |
| In-network Lab Orders | YES | Usually | Depends on the HMO plan and individual needs |
| HMO Insurance Physicians | Out of pocket cost | Direct Pay Option | Notes |
| Out-of-network Primary Care Physician | Out-of-network rates per HMO plan. | Yes, but not advised | Generally, HMO’s make it difficult to retain a private physician |
| Out-of-network Specialist | Out-of-network rates per HMO plan. | Yes, but not advised | HMO’s make it difficult and more expensive to work with out-of-network specialists. |
In-network Specialists: Accept Referral from in-network providers. No guarantee they will accept referrals from out-of-HMO providers.
In-network Imaging Centers: Accept Referral from in-network providers. No guarantee they will accept referrals from out-of-HMO providers.
In-network Labs: Accept Referral from in-network providers. No guarantee they will accept referrals from out-of-HMO providers.
Out-of-network Specialists/labs/imaging centers: may be subject to more out-of-pocket expense depending on circumstance.
Out-of-HMO primary physician: may be subject to more out-of-pocket expense depending on circumstance; Difficult to direct pay for an out-of-HMO primary care physician.
- Medicare. The federal program that worker’s pay into over the years that will cover a wide spectrum of services once eligible -- usually after the age of 65. Exceptions include social security disability.
| Medicare
Referrals |
Accept Medicare Provider Referrals | Accept Opted-Out Provider Referrals | Notes |
| Specialists | YES | YES | |
| Imaging Orders | YES | YES | |
| In-network Lab Orders | YES | YES | |
| Medicare Physicians | Out of pocket cost | Direct Pay Option | |
| Opted Out Primary Care Physician | Free market pricing, fee for service | YES, only if provider is opted out of Medicare | Direct Primary Care is a model of payment whereby the patient pays a membership fee in exchange comprehensive primary care services |
| Opted Out Specialist | Free Market, Fee for Service | YES, only if provider is opted out; | Only select markets have specialty care membership models |
Opted-In Specialists: Accept Referrals from BOTH Medicare and opted-out providers
Imaging Centers: Accept Referrals from BOTH Medicare and opted-out providers
Labs: Accept Referrals from BOTH Medicare and opted-out providers
“Opted Out” primary physician: may be subject to out-of-pocket expense depending on circumstance; ok to cash pay or direct pay out-of-network primary care physician (Medicare is not billed for visits in favor of a monthly or other retainer membership fee -- see “direct primary care”).
- Medicaid. A State-funded program that covers qualifying individuals for certain healthcare expenses, often up to 100%. To qualify one must meet income and/or disability metrics. Many regions will have government-funded/backed facilities (usually primary care) to care for this population. Likewise, in many regions, very few providers will accept Medicaid due to low reimbursements.
| Medicaid Referrals | Accept Medicaid Providers Referrals | Accept Non-Medicaid Provider Referrals | Notes |
| Medicaid Specialists | YES | YES | |
| Imaging Orders | YES | YES | |
| Lab Orders | YES | YES | |
| Medicaid - Physicians | Out of pocket cost | Direct Pay Option | |
| Non-Medicaid Primary Care Physician | Free Market Pricing, Fee for Service, | No | Medicaid rules generally prohibit cash payment for services covered by Medicaid |
| Non-Medicaid Specialist | Free Market, Fee for Service | No* | *It may be possible to direct payment if there are no specialists in one’s regions accepting Medicaid |
Medicaid Specialists: Accept Referral from BOTH Medicaid providers and non-Medicaid providers.
Imaging Centers: Accept Referral from BOTH Medicaid providers and non-Medicaid providers.
Labs: Accept Referral from BOTH Medicaid providers and non-Medicaid providers.
If you are on Medicaid as an adult, it is generally not ok to cash pay or direct pay non-Medicaid primary care physicians. Children on Medicaid may be able to retain a private, non-Medicaid, physician. Either way, it is best to consult with your State’s Medicaid office to be sure.
- Health Cost-Share. Though technically not health insurance, the rise in popularity of traditionally faith-based health share plans, and more recently, secular cost-share programs warrants inclusion in the discussion of the “types of coverage”. Health share companies make it a point that members are to approach all healthcare services as “cash-pay” patients. As a result, patients are billed at cash-pay rates. Invoices are submitted by patients themselves to the company as a “share” request. Depending on one’s “Initial Unshared Amount” (IUA) - which can range from $500-1500, the community will pay off the medical bills through “shares”. There are no health share networks per se. However, some cost-share plans (Sedera) provide discounts on their membership fees when pairing the membership with a Direct Primary Care practice. Each sharing plan has its own set of stipulations. Here is one reference to help sort some of the more popular health cost-share plans out:
| Health Sharing/Cost Sharing - Referrals | Accept In-network Provider Referrals | Accept Out-of-network Provider Referrals | Notes |
| Specialists | n/a | n/a | Since health share plans are not insurance and not network-based, one can see any specialist |
| Imaging Orders | n/a | n/a | Able to go to any imaging center |
| Lab Orders | n/a | n/a | Able to go to any lab |
| Health Cost/Health Sharing - Physicians | Out of pocket cost | Direct Pay Option | |
| Primary Care Physicians | Cash Price, Fee for Service, Membership Pricing Initial Unshared Amount (IUA); | YES | Health share plans pair well with DPC practices, often saving people 40-50% vs. traditional insurance plans |
| Specialist | Cash Price, Fee for Service, Membership Pricing; Initial Unshared Amount (IUA) | YES |
- Uninsured / Cash Pay. Despite the now-defunct mandate by the Affordable Care Act (ACA) to require health insurance or be penalized, many Americans forego insurance coverage for one reason or the other. With rising premiums and no tax penalty, many are taking the leap into free-market medicine. As a result, the market is slowly responding with more transparency and cash pay services. Direct Primary Care is gaining momentum as primary care physicians are fed up with third-party payor burdens, burn out, and advocate for a more personal patient-doctor relationship. Direct imaging, lab, specialists and even hospitals (e.g. Surgery Center of Oklahoma) are even dipping their toes into direct care. The stigma of not having insurance is slowly dissipating.
| Health Sharing/Cost Sharing - Referrals | Accept In-network Provider Referrals | Accept Out-of-network Provider Referrals | Notes |
| Specialists | n/a | n/a | Since health share plans are not insurance and not network-based, one can see any specialist |
| Imaging Orders | n/a | n/a | Able to go to any imaging center |
| Lab Orders | n/a | n/a | Able to go to any lab |
| Health Cost/Health Sharing - Physicians | Out of pocket cost | Direct Pay Option | |
| Primary Care Physicians | Cash Price, Fee for Service, Membership Pricing Initial Unshared Amount (IUA); | YES | Health share plans pair well with DPC practices, often saving people 40-50% vs. traditional insurance plans |
| Specialist | Cash Price, Fee for Service, Membership Pricing; Initial Unshared Amount (IUA) | YES |
Referrals
| Type of Health Insurance coverage | Accept Referrals from Out-of-Network/DPC Primary Care Physician? |
| Private Insurance (e.g. BUCAH’s**) | Yes |
| Private - HMO | Sometimes* |
| Medicare | Yes |
| Medicare HMO | Sometimes* |
| Medicaid | Yes |
| Cash Pay/Uninsured | Yes |
*Some HMO’s will accommodate outside of network referrals and there are always situational exceptions
**BUCAH = Blue Cross Blue Shield, United, Cigna, Aetna, Humana
***Referrals include specialist consultations, diagnostic studies, imaging/x-ray orders, and lab orders
HMO - Health Maintenance Organization
Let's look at a possible scenario:
A 50-year-old male has United Healthcare insurance through his employer. It is NOT an HMO plan. He is looking for a primary care physician and searches online for a PCP that “accepts” United. He calls several offices and is told that he may either wait 4 months to establish care with a physician or 2 weeks to establish care with a physician assistant (PA). He elects to see the physician assistant to get things rolling since he would like a complete physical. He has his appointment, but the PA tells him that he’ll have to see a physician for the complete physical. In the meantime, the PA refills his medication for blood pressure. He is referred to a cardiologist since he mentioned that he experiences chest pain on occasion, but he has been under quite a bit of stress at work. The appointment was brief and mostly consisted of data entry into the system. He has a rather high-deductible, and he pays his co-pay of $30 at the time of service.
In-network PCP experience: Long wait to get in with a physician, less wait to see a mid-level provider. The visit is brief and impersonal and subject to a co-pay. He is referred to a specialist in-network, in the same organization.
This same 50-year-old male with United Health decides he would like to establish care with a private physician who does not accept insurance. Rather, he pays a monthly retainer fee for comprehensive direct primary care. He gets an appointment within 24 hours. The appointment is an hour long. Labs are obtained as well as an EKG and an extensive medical history intake and physical exam. The physician is not rushed and he comes away feeling rather satisfied. Plus, he knows he can speak directly with his doctor at any time, as long as he is a member of his practice. A referral to a cardiologist could be handled just as well by this out-of-network primary care physician because what matters is whether the cardiologist is in-network or not...not the PCP.
Out of network PCP experience: Seen by a physician quickly. The exam is thorough, relaxed and extended. No copay for visits because all visits are included in the membership fee. Still able to see specialists and get labs/imaging just fine. He has a direct line to his physician. Saved him time and hassle factor getting a comprehensive physical and answers to his medical questions sooner than later. The time saved more than makes up for the monthly retainer fee, plus he can budget appropriately knowing that his primary care expenses are fixed and transparent through his DPC physician.
Bottom line: Unless you have an HMO-type of health insurance, choose the private physician YOU want and don’t worry about whether or not he/she takes your insurance.
There are a lot of potential scenarios of “who pays for what?” when it comes to the healthcare experience. Despite the marketing message from health insurance companies and the brokers strongly suggesting that you should only see in-network physicians, know that you may choose an independent, out-of-network physician and not worry about whether or not you can be referred to a specialist, lab, or a diagnostic center. Your out-of-pocket expenses may or may not be higher depending on your coverage.
If you have any questions, please do not hesitate to contact us.