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It's hard enough not feeling your best, but having to deal with the constraints of managed care can make it even worse. If you or your spouse change jobs, your employer changes health insurance contracts, or your neurologist decides to opt out, you may find that your insurance benefits no longer cover your doctor visits. It can happen at any time and really disrupt your care. But if you're comfortable with your neurologist and just don't want to switch, is there anything you can do? You bet.
Health maintenance organization (HMO) members are required to see doctors who participate in the plan. If you have a preferred provider organization (PPO), you may choose to go “out-of-network” to any provider. But it's likely you'll face added costs, including higher deductibles and copays. The out-of-pocket expenses vary among insurance companies, so be sure to call and find out about them in advance.
Kelly Curran's 4-year-old daughter, Jenelle, was first diagnosed with epilepsy by in-network neurologists when she was 10 months old. But after the doctors had tried numerous seizure medications without success, they referred her to UCLA's Director of Pediatric Epilepsy, W. Donald Shields, M.D. Curran credits her daughter's dramatic improvement to Dr. Shields' expertise and experience.
“Whereas general pediatric neurologists may have seen one or two patients with Jenelle's rare form of epilepsy, Dr. Shields has cared for hundreds, and that made all the difference,” she says.
Curran's employer has had two different insurers over the past four years, both of which allowed her daughter out-of-network subspecialty care at UCLA. Curran encourages patients and family members to be persistent in requesting that their insurance companies provide a second opinion by a non-participating doctor if the condition requires a subspecialty perspective or a physician with specialized expertise.
Health insurers consider travel time as a factor in providing out-of-network doctors. If you need a neurologist or neurological subspecialist and there is none within a reasonable distance, ask about the plan's guidelines. Of course, what is considered “reasonable” varies from plan to plan; some consider it to be “30 minutes travel or 30 miles,” but you'll have to check with your insurer.
The Centers for Medicare & Medicaid Services, which creates the regulations for private insurance companies that provide Medicare services, states that the organization must arrange for specialty care outside of the plan's provider network when network providers are unavailable or inadequate to meet an enrollee's medical needs.
Medicare managed-care organizations must also ensure that providers are distributed so that no member living in the service area must travel an unreasonable distance to obtain covered services. Depending on the state in which you live and the specific carrier rules, you may be eligible for services outside the network simply because there are no in-network neurologists within a specified travel time.
If your employer provides several insurance options, in most cases, you can consider making a switch at a designated time each year. When Michael Kaplan was given a choice of insurance plan options by his employer, Microsoft, he selected a plan in which his neurologist participated because he wanted to stay under her care.
“I trust my neurologist, so it was a simple choice” says Kaplan, who was diagnosed with multiple sclerosis in 1991. He had worked with many neurologists in his prior role as an EEG technologist, and knew a great deal about his condition.
“This made me a bit of a snob about only wanting to see a neurologist who really knows her stuff and gives me the straight scoop.”
When Curran's employer changed insurance plans, she was assigned a “transition assistant” who ensured continuity of treatment with Jenelle's existing specialists and medical supply provider, and pre-authorized all services so there would be no missed appointments. If you are making a change, ask your insurance carrier if they can provide a specialist to assist you with the administrative issues related to the switch.
Case managers are agents within insurance companies who serve as liaisons between patients and insurers and advocate for patient needs.
“Anyone with a chronic illness should request a case manager,” Curran advises. The designated representative, often a nurse, oversees all authorizations and referral requests and serves as a primary contact for all medical needs.
More and more doctors have begun to pull out of managed care altogether. Michael J. A. Robb, M.D., a medical neuro-otologist in Phoenix, Ariz., who doesn't participate in any insurance plans, advises his HMO patients to ask their primary care physician (PCP) to request an out-of-network authorization for his consultation.
“This increases the likelihood that patients will be reimbursed, and PCPs are often willing to help out,” he says.
Dr. Robb asks patients to pay what is within their budget at the time of service and to send the balance on a schedule they select. Similarly, most doctors' offices are willing to work out payment plans. Dr. Robb also directs his tinnitus patients to request American Tinnitus Association assistance grants, which subsidize up to $1,500 of the costs of devices, visits to health care professionals, or associated travel costs.
New Orleans neurologist Michael T. Happel, M.D. knows all too well what it's like for patients to suddenly lose their health care benefits along with their jobs. He, like many New Orleans physicians, now provides care to a number of his former patients without compensation, despite his own skyrocketing expenses.
“I think it's immoral to stop seeing patients just because they can't afford it,” Dr. Happel says, adding, “Some of my patients have lost everything. How can I turn my back on them now?”