Quote:
Originally Posted by Miles42
The real problem lies with the fact we went with the UHC system touted by the Villages this past January. With the health care plan we had before we could have gone to see the Dr in Jacksonville with no problem. Now getting the approval for anything has been a nightmare.
|
Actually, the real problem is that all over the country for the past 5 years or so getting an insurance co. to approve a procedure, test, or out of network referral has been like pulling teeth. Your PCP needs to document in his progress note the exact reason for the out of network referral and why the same care cannot be rendered in network. That note gets sent with the referral request to the insurer, who will give an answer in 1-2 days. If denied, your PCP can speak with the medical director at the insurance co. and convince him to approve the request. It's a pain in the butt, however I never had a request denied after speaking personally with their medical director in 30 years of practice. But the yardstick HAS to be that the doctor in Jacksonville performs a procedure or specializes in something NOT available in network, not just my neighbor saw him or I like his biography on a website. These insurance co. rules are beyond the scope of TV Health, or any practice for that matter. But you should have had an answer within a week of seeing your PCP. After that, the waiting time to see this specialist is up to him only. Some insurers allow self referral to specialists, but less and less these days, and many specialists won't see a patient who has not been referred by a PCP. So don't assume it would have been any different with another PCP or a different insurance plan, not these days. Welcome to the new reality of health care in the U.S.---remember, "elections have consequences"