Requesting Out of Network Coverage for Psychiatrist

Peter Forster Costs of Treatment, Policy

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.

  1. 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.
  2. As a result psychiatrists often  do not contract with insurance companies, or limit the number of patients that they accept from insurance  companies.
  3. 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:      

  1. Employer’s Medical Benefits Coordinator
  1. (Your own) State Senator **
  1. (Your own) State Assemblyperson **
  1. 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

                        www.hmohelp.ca.gov         

  1. 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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