Updated: October 9, 2024
By Virginia Brown , Jesse Ketterman , and Suzanne Cooke
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FS-1022  |  2015, updated September 2024

How do I Choose a Primary Care Provider? Ask the Right Questions

Doctor talking with his patient
Image Credit: Adobe Stock

After careful consideration, you have chosen a health insurance plan. Now you need to make smart use of that plan! Choosing a primary care provider should be one of your first steps toward using your insurance plan to obtain good health care. In general, most of us need a primary care provider (one who directs or coordinates a range of health care services); others may also need specialists.

Primary Care Provider: A physician (a Medical Doctor or M.D., or a Doctor of Osteopathic Medicine or D.O.), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services. (healthcare.gov, 2024)

Follow these four steps and ask the questions to help you choose your primary care provider.

Step 1: What do I need to know to choose a primary care provider?

Before you can select a primary care provider, you need to know which providers accept your health insurance plan.

The provider you choose could affect the quality of your health care as well as how much you will pay.

Health insurance plans often have a network (see, “Important Words to Know about Health Insurance”) of providers who have an agreement with the health plan to charge a set lower fee for services. Seeing one of the participating providers in a network is the best value. If you choose a provider that is out of the network, you may pay more than if you select one that is in the insurance company’s network.

To make sure the health insurance plan works with the primary care provider, you need to answer three questions:

  • Does my health insurance plan have a network?
  • Does the provider participate in my plan’s network?
  • Is the provider accepting new patients?

 

 

Step 2: Where do I go for information about selecting my provider?

There are two main sources for information about the specifics of your health insurance plan and the participating providers:

  1. Your insurance company; and
  2. Your employer’s Human Resources department, if you get insurance through work.

You can find information from the insurance company in three places:

  • Evidence of coverage (see “Important Words to Know about Health Insurance”);
  • Insurance company website; and/or
  • Insurance company information telephone service.

Step 3: What information should I obtain and what questions should I ask my insurance company?

You need to answer five questions to choose a primary care provider. You may be able to find answers to the following five questions online or by calling the insurance company:

  • Is the provider in my network?
  • Where is the provider’s office(s) located?
  • Is the provider affiliated (can treat people) with a local hospital?
  • Does the provider have a specialty?
  • Is the provider part of a practice or is it a sole provider office? (see “Important Words to Know about Health Insurance”)

Step 4: How do I use this information?

With answers to the five questions in Step 3, conduct additional research to ensure the provider is a good fit for your needs. Be sure to:

  • Ask others you trust about the providers you are considering. Inquire about the provider’s reputation, the kind of relationship the provider has with patients, and any other information you want to know.
  • Compare primary care providers and hospitals online. There are several resources that will let you know how well the providers and hospitals perform. These include:
  • Call the provider’s office to ask if the provider is accepting new patients and how the office staff handles billing. When you call the office, you will want to ask:
    • Is the provider or practice accepting new patients?
    • Do you still participate in the insurance plan’s network?; and
    • Do you bill the insurance company directly?

Once you have all this information, you are ready to make your first appointment.

Remember:

  • Provide your loved ones and the health insurance company with the name and contact information of the provider you chose;
  • Keep records of the services and bills received and payments made.

“Choosing the Right Provider” Information Form

General Information:

Name of Primary Care Provider ___________________________
Age of Provider ____ Sex of Provider ___ Years in Practice ____
Name of Practice ______________________________________

Information about the Primary Care Provider:

  1. Is the provider in my plan’s network?  ☐ Yes  ☐ No
  2. Where is the provider located?
    1. Miles from work _______
    2. Miles from home _______
  3. Is the provider affiliated with a hospital? Which one?
  4. Does the provider have a specialty?
  5. What type of practice are they in? ☐ Multi-provider  ☐ Sole Provider

Primary Care Provider’s Reputation and Grade

  1. What do others say about the primary care provider?
  2. What are the provider’s and hospital’s grades and from which website did you obtain the information?
    1. Provider _______
    2. Hospital _______

Information from the Primary Care Provider

  1. Are they accepting new patients? ☐ Yes  ☐ No
  2. Did they confirm they participate in the plan’s network? ☐ Yes  ☐ No
  3. How do they handle billing?
    1. You pay upfront and self-submit for reimbursement ☐ Yes  ☐ No
    2. They bill the insurance company, and you pay the difference ☐ Yes  ☐ No

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