EXTENDING MEDICAL BENEFITS TO NON-PREFERRED PROVIDER PHYSICIANS
Some of the most heartrending calls that we receive from potential patients have to do with people who are unable to find psychiatrists who are covered under their insurance plan. One solution may be to request out of network coverage for a psychiatrist.
Background
There are several problems that make this a common problem.
- Insurance companies have for decades paid psychiatric physicians less than other physicians even though psychiatrists have as much or more training as other specialists. These practices haven’t changed that much despite the passage of parity legislation.
- As a result psychiatrists often do not contract with insurance companies, or limit the number of patients that they accept from insurance companies.
- Insurance companies often list many physicians in their directory who are not available to see patients for outpatient care. For example, psychiatrists who teach in residency training programs are listed in directories because the services they provide as part of their supervision of psychiatric trainees are billed for by the training program, However services provided outside of the residency training program may not be billed for through the insurance plan, and directories don’t mention that fact.
The key thing to be aware of is that insurance companies are legally required to have accessible care to the individuals they cover.
A colleague and friend has developed a process for trying to get services in these situations.
Get a list of covered psychiatrists
Go online or, better, call your managed care company and request a list of board eligible or board certified psychiatrists in your area who are covered by your insurance plan. If there any special needs ( for example if you need child or adolescent psychiatrist or a psychiatrist with particular expertise) mention those when you call the managed care company.
Go through the list and identify 10 psychiatrists who seem to be a good match.
Call psychiatrists and track these calls
Create a table or spreadsheet to track when you call and what the results of that call are. If you call and leave a message document that fact. Then track when and whether you receive a return phone call. I recommend that if you have not heard back from a psychiatrist’s office within two days that you leave an additional message.
Here is a sample…
| Psychiatrist Name | Date and Time of Call | Result | Return Call | Followup Call | Notes | ||
| John Schwartz | 5/9/16 2:02 pm | Left message | Never received | 5/11/16 3:04 pm | Never heard back | ||
| Amy Andrews | 5/9/16 2:06 pm | Left message | 5/10/16 8:01 am | Not taking new patients | |||
Write a letter
Use the template letter below only if your insurance company cannot provide you with a board eligible or board certified psychiatrist within an appropriate time frame and at an appropriate distance from home.
Letter template
Modify this letter to fit your situation.
Dear (Director of the Insurance Company’s or Health Plan’s Member Services Department):
I suffers from (name of the psychiatric disorder). Because of the (specific circumstances) I need to be evaluated and treated by a board eligible or board certified psychiatrist.
I have attempted to use the Preferred Provider panel of psychiatrists offered to us by (name of the Insurance Company or Health Plan)’s representative (name of the contact at the Insurance Company or Health Plan). We have contacted (number) different (or “all”, if all names offered have been called) psychiatrists whose names were given to us by your representative (name of the contact at the Insurance Company or Health Plan) and have discovered they are either not board eligible or board certified psychiatrists, have no current availability, are beyond a (number) mile radius of our home, or failed to return our call. It appears our provider list is a “phantom list”, one that exists on paper but which, in fact, offers no appropriate coverage for a covered benefit.
I have been in contact with Dr. (name of doctor), a (board eligible or board certified – whichever is appropriate) psychiatrist in (name of the psychiatrist’s city) who can evaluate and treat me immediately. I request that you extend my benefits to cover care with Dr. (doctor’s name) since (name of Insurance Company or Health Plan) is unable to provide us with an appropriate physician in an appropriate time frame and at an appropriate distance from our home.
I further request that coverage for Dr. (doctor’s name)’s services be at (her/his) rates and our co-pay and deductible be equal to that for a preferred provider, since no preferred provider is available.
[OPTIONAL, depending on the circumstances of the physician’s office policies: We will pay Dr. (doctor’s name) at the time of service, and request reimbursement to us of (her/his) fees minus our contracted co-pay and deductible.]
I purchased insurance with (name of Insurance Company or Health Plan) with a good faith belief that contracted benefits would be available. I continue to regularly pay my premiums with that same good faith belief. Please provide coverage for my contracted benefit in a medically appropriate manner.
Thank you.
Sincerely,
Cc:
- Employer’s Medical Benefits Coordinator
- (Your own) State Senator **
- (Your own) State Assemblyperson **
- California Department of Managed Health Care
California HMO Help Center
980 Ninth Street, Suite 500
Sacramento, CA 95814
Phone: 916/324-8176
HMO Patient Helpline: 888/466-2219
- California Department of Insurance
Consumer Communications Bureau
300 South Spring Street, South Tower
Los Angeles, CA 90013
Phone: 1/800-927-HELP (4357)
www.insurance.ca.gov
** To find your state senator and assembly person use this link.
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