[jstrom]

You can theory-craft a non-malicious justification: Insurance trusts Dr. Hibbert will perform the procedure without complications and has negotiated a fixed price of $1K. Insurance doesn't trust Dr. Nick and believes any procedure he performs will result in a second claim later to set things right. Insurance strongly wants you to chose Dr. Hibbert and the only leverage they have is to refuse to pay for Dr. Nick should you go with him.

Not sure how plausible that is though--I suppose they could data-mine frequency of follow-up treatment required per doctor--but I've never observed in network/out of network to correspond to a meaningful metric (our local dentist recommended by all the dental specialists around doesn't deal with any insurance companies, while the in-network dentist is pretty clearly padding their work)

[inetknght]

Why doesn't the insurance company trust Dr. Nick?

If there's reason to not trust Dr. Nick, then surely the insurance company must disclose it. If there's reason to not trust Dr. Nick, then surely Dr. Nick would have trouble maintaining a medical license. If there's reason to not trust Dr. Nick then surely Dr. Nick's own malpractice insurance would become too onerous for him to keep.

No, this smells exactly like what @Someone1234 stated:

> Out-of-network was always just a sketchy way for insurance to avoid paying what they should have paid.

[jrs235]

Sometimes the trust issue is more about fraudulent claims than one's ability to practice medicine...

[jakelazaroff]

Then why is he still in business? If he's committing insurance fraud, then the insurance company should work with regulators to stop and potentially prosecute him. The onus to prevent fraud should not be on me as a patient.

[inetknght]

> If there's reason to not trust Dr. Nick, then surely the insurance company must disclose it.

That should include "we think Dr. Nick makes fraudulent claims"

[LorenPechtel]

Yeah. There is a legitimate quality reason but it doesn't appear to be how they actually operate. Reality is more like a local case that resulted in a lawsuit (never heard the outcome) against the insurance company for sending patients to your Dr. Nick.

[monknomo]

I mean, Dr. Hibbert might refuse to be in network for some insurance company because he doesn't like their rates. I think that's more common