Working within a managed care health plan (HMO or PPO) can be simple, as long as you follow the simple guidelines that were given to you when you signed up for the plan. But what happens when you or your dependents require services outside of what the plan will cover? For instance, you would like to go to an out of state specialist for a second opinion concerning a cancer diagnosis or you would like you child with cerebral palsy to receive cutting edge therapy that is not yet FDA approved.
The basic premise of both HMO and PPO plans is that in order to receive full coverage for medical care you must receive services within their network of providers. If you have an HMO no claims will be paid for non-network services without a referral. For those in a PPO plan payment of these non-network claims will be at a much reduced rate. Therefore, it is imperative that you get proper authorization for non-network care otherwise you may be asked to pay hundreds or thousands of dollars in out of pocket expenses.
Your closest ally in trying to get approval for non-network services will be your primary care physician (PCP). As a managed care patient, all of your care should already be coordinated by your PCP and they will be in the best position to know what are the most appropriate medical treatments for your condition. Once you and your PCP have determined that out of network care is required, ask him to write a letter pleading your case. Along with this letter, be sure to gather together any letters from specialists and diagnostic test results relative to your condition. You may also want to do a bit of research on your own that will support your case. Browse the internet to find articles or studies that support the medical services you are trying to get approved.
Next you will draft the actual letter to your insurance company. Be sure when you address the letter it is going to their street address and not a PO Box. Within your letter indicate why you feel non-network care is warranted and try to be as specific as possible. Be also very comprehensive about what you are asking to be included in your referral. Are you asking for just a second opinion? Are you requesting lab work in conjunction with an office consultation? Are you looking to have more than one appointment? In your letter clearly state when you expect a response from the insurance company, but a reasonable timeline is approximately two weeks. Remember to be pleasant yet assertive in the tone of your letter. The old adage about catching more flies with honey than with vinegar is absolutely true. Once your letter is fully crafted be sure that you send the letter via certified mail.
Being ill or injured is unpleasant at best. At worst, it is painful, frightening and overwhelming. Dealing with your insurance carrier in order to get the medical care that best suits your condition should not be an additional stress that is heaped upon your already frail self. Follow these guidelines closely and you should soon be on a pathway to healing.
Written by Sue De La Bruere
