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Why Won't Some Doctors Accept Certain Insurance?

Generally speaking, the only reason doctors would not accept any or certain types of insurance is because they believe they are better off financially by not doing so. Doctors often receive less income on insurance work because they are bound by contract fees agreed to with group or managed insurance policies.

  1. Insurance Networks

    • Health insurance networks have become fairly common in the early 21st century. Many employees are part of employer-group networks that are often partially or wholly paid for by companies. These insurance networks are essentially three-way agreements between the insurer, policyholder and providers that are part of the network. The policyholder is guaranteed benefits coverage in specific areas by the insurance company. Providers that agree to participate in a given insurer's network agree to contract prices for various services covered by the insurance. Policyholders get better benefits by using in-network providers.

    Pros and Cons for Doctors

    • Participating in insurance networks has pros and cons for medical providers. The main advantage is that participation makes the provider more readily available to serve the market of people covered by the insurer's plan. By opting out of participation, the provider realizes they likely will not receive many visits by the policyholders covered under that plan. Drawbacks are that the provider typically agrees to contract rates that are often well-below what he could get from private pay clients and more bureaucracy and paperwork is involved.

    Refusing Insurance

    • In essence, doctors that choose not to accept insurance decide it is better for them and their practice to work only with private pay clients. "USA Today" notes that typically only 1 in 10 doctors works solely with private pay clients. In these instances, the client or patient simply pays the doctor at the time of the visit for the entire fee for service.

    Marketplace Pros and Cons

    • Maggie Mahar of Health Beat notes that more doctors are fed up with the "red tape" and hassle of dealing with private insurers. They say the clients gained from accepting insurance are not worth the time involved and the fee disputes. "USA Today" indicates that uninsured people benefit the most from this arrangement as doctors often offer lower fees when working strictly with uninsured. Those same uninsured people would likely pay significantly higher rates with providers that do accept insurance. Those people covered by insurance still typically have a wide-enough network of providers to choose from.

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