Approved!

Approved doesn't always = In Network

Example:

Let's say an out of town college student comes home for the holidays to have surgery in his/her hometown and then returns to school a few weeks later and plans to complete his/her physical therapy at a facility closer to campus.  Unfortunately the insurance policy his/her parents cover them under restricts in network facilities to a 50 mile radius of their hometown with no out of network benefits.  

Option 1: The patient could go to an out of network facility any way, but the insurance carrier would likely deny the claims and the physical therapy facility could balance bill them (ie. they owe the full billed amount with no contracted discounts.)

Option 2: The patient can request that the ordering physician's (the surgeon) office submit an authorization request along with a letter of medical necessity from the doctor to the insurance carrier requesting that they allow the patient to seek physical therapy at an out of network facility due to the fact that he/she attends school outside the 50 mile radius. 

    If approved the patient would be allowed to seek treatment at the out of town facility, but would be subject to their out of network benefits (probably a large deductible amount would need to be met before the insurance carrier would pay anything, but it would allow some discounts)

    If denied, there's still hope! 

         a. A patient has a right to appeal the decision of the insurance carrier, though it can become a long drawn out process, sometimes it's worth the fight.

         b. Sometimes health insurance plans will allow (or even request) a "peer to peer" with the requesting physician and the medical director (a doctor who works for the health plan that makes decisions regarding medical authorizations).  Often times this can be difficult to coordinate, but it can help if the requesting physician appeals directly to the medical director. 

So keep in mind "approved" doesn't always mean in network. 

Shopping around for your own private health insurance policy and feeling confused and overwhelmed? I can help you better understand what each policy offers and what it means to your pocket book now vs. later. 

Send your questions to:

deargabbyinsurance@yahoo.com