UPDATE: We have been unable to negotiate a contract with United Health Plan and their subsidiaries. However, we no longer participate with them. We can still see some of their patients out of network.
Please call and tell your insurer that you want to stay with your doctor and they should make any necessary efforts to keep him in the panel.
Overview
What your options are in reference to NON-PARTICIPATING physicians if you have:
- A traditional HMO
- HMO opt-out plans without out-of-network benefits
- HMO opt-out plans with out-of-network benefits
- Non-HMO indemnity plans
Traditional HMO
Includes:
- Aetna
- Optimum Choice / MDIPA
- CareFirst BlueChoice
- CareFirst POS Plan
- Kaiser
It is important to note the following:
- Members with traditional HMO benefits can see a participating physician or facility only when referred by their PCP. (need a referral).
- Members may not see a non-participating physician even with a referral. If a member wants to see a non-participating physician, the member needs to sign a strictly cash arrangement waiver. the physician’s office must collect all fees at the time of service. No claims may be filed with the carrier by either party. HMO carriers will not reimburse services rendered by a non-participating physician in an out-patient setting.
- According to the Maryland state law, if members are treated in a trauma or in-patient situation, the carrier must pay the non-participating physician fee. Under these circumstances, physicians must be aware that they may need to file an appeal (s) and therefore payments can be delayed.
HMO opt-out plans without out-of-network benefits
Includes:
- Optimum Choice / MDIPA
- Kaiser
It is important to note the following:
- Members without out-of-network benefits can see a participating physician in an out-patient setting without a referral.
- Members may not see a non-participating physician even with a referral. If a member wants to see a non-participating physician, the member needs to sign a strictly cash arrangement waiver. the physician’s office must collect all fees at the time of service. No claims may be filed with the carrier by either party. HMO carriers will not reimburse services rendered by a non-participating physician in an out-patient setting.
- According to the Maryland state law, if members are treated in a trauma or in-patient situation, the carrier must pay the non-participating physician fee. Under these circumstances, physicians must be aware that they may need to file an appeal (s) and therefore payments can be delayed.
HMO opt-out plans with out-of-network benefits
Includes:
- Aetna Open Access
- CareFirst / BlueChoice Open Access
- CareFirst POS
- Optimum Choice/MDIPA Preferred
It is important to note the following:
- Members with out-of-network benefits can see a non-participating physician in an out-patient setting without a referral.
- Members need to sign an out-of-network waiver, agreeing to pay balances unpaid by the carrier.
- Members may assign benefits to the physician. Depending on the carrier, assignment of benefits may not be recognized. Under these circumstances, the carrier may send the payment to the member, rather than the physician directly. In which case the patient must endorse the check to the physician and send it in.
- According to the Maryland state law, if members are treated in a trauma or in-patient situation, the carrier must pay the non-participating physician fee.
Non-HMO indemnity plans
Includes:
- Alliance PPO
- BCBSNCA Federal CareFirst MD
- Cigna
- MAMSI Life & Health
- United Healthcare
It is important to note the following:
- Members with indemnity plans can see any physician in an out-patient setting or in-patient setting.
- Members may assign benefits to the physician. Depending on the carrier, assignment of benefits may not be recognized. Under these circumstances, the carrier may send the payment to the member, rather than the physician directly. In which case the patient must endorse the check to the physician and send it in.
- Physicians offices are not required to have members sign a waiver to collect payments for services rendered.