Request to go out of network denied

I have a PCP that is out of network that I private pay for. The insurance company is aware of this. I called 6 months ago to discuss it with them and was told that I woud still have access to the same care and that other than having to pay for the appts it wouldn't affect anything. 

So now they are saying that since my PCP is out of network the request to go out of network, which is my only chance to get a DS is invalid and I do not have appeal rights. I would have to change my PCP and resubmit but then there is no guarantee that it would be approved. 

I don't get it. They take her prior auth on CT scans, meds, surgery clearance, everything else. 

So, I either change my PCP that I LOVE and have known for a long time, or no DS. 

But I could leave and still not get my DS.

I sure do wish I had that conversation about my PCP from 6 months ago in writing. 

Not sure what to do at this point. I just need to sleep, think it over and regroup. 

Stupid insurance..... 

 

So sorry to hear about that.  Just remember that it will ALL WORK OUT for YOUR GOOD.  I am saying a prayer for you to have clarity on your next steps.  Hang in there!

So frustrating that healthcare is completely insurance-driven.  Almost makes one wish for socialized medicine, but that comes with its own set of issues.

It seems as if you are not going down without a fight.  Just try to remember, that everything happens for a reason, and whatever decision you make, will be the right one.

Good luck to you with this ongoing battle.  If you want something bad enough, and it sounds like you do, it will come to you in the long run.

Sweet dreams......

.....nothing about what you wrote is not known. why should your insurance co. pay, you have broken the contract rules.... in order for you to get out of network benefits, an approved in network pcp must refer you out to a bariatric surgeon this is customary.  no out of network pcp can make any referral, none, you have to know the rules and follow them, break any of them and you will expectedly be denied.  there is never a guarantee of benefits, that is actually on every EOB.  any dr can order blood work, rx etc.  surgery clearance is nothing, the insurance co doesn't give a rat's ass about surgery clearance, that is for the surgeon not the insurance co....you have to decide what you want, your pcp to refer you and to be denied, since you are knowingly going against your contract, or an in network pcp to refer you to a specialist, bariatric surgeon,  you really need to get your subscriber agreement, read it, understand it, and know it well,it is your responsibility,  all the information you need is outlined there, the insurance co relies on people to not read their subscriber agreement, because they know if they did, most denials wouldn't happen or would be quickly appealed....  requesting bariatric surgery and not knowing your rights is like a lamb going into a lion's den....

Get a different PCP in network, at least temporarily, to request the DS.  Using all the rest of the documentation you already have, you can hopefully get approved quickly.  Post surgery, you can always return to your fave PCP.  Do what you need to do to get what you need.

Excellent advice!  

I agree. Get another PCP get your surgery then go back. 

Don't worry - just get an in network PCP for  a while.  Time will fly by.

Yeah, no big deal. Get in network pcp, get DS, go back to fave pcp. Another hoop jumped through. You're almost there, don't give up.

I know each time your denied your heart sinks when you are trying to get your surgery but it's a long journey ahead  you have plenty of time, you can keep your pcp just get an in network one to work with you through this. Maybe your pcp you have now can suggest someone for that purpose? Best of luck

 

Trish