PPO question/DH requirements?

[FLMommy]

What is the name of your state? Oklahoma

Is it true that there are Department of Health requirements which state there must be a participating doctor of each specialty within a certain mile radius of each zip code in each county in order to actually sell insurance into that county?

We just moved from FL to OK (maintaining same health insurance) and our daugther needs to see a pediatric neurosurgeon on a regular basis. The ONLY 2 pedicatric neurosurgeons in the ENTIRE state are working at OUMC in OKC which for some mind baffling reason is not part of our PPO network.

Assuming that the hospital/physicians are not interested in contracting with our insurance company (though one of them is listed as PPO, but at his former employer in a different state, not at this hospital) and if the above is true (DH requirements), is either the insurance company or the hospital/physicians in question required to charge us the participating provider amount? Is our insurance co. required to allow us to see a non participating provider at the in-network benefit level since the access requirements aren't being met?

Any suggestions In the meantime will go through the process of 'referring' the dr and hospital to our ins. co, have them send a packet, and see if the physician wants to contract with them again, but a process like that could take a half a year, and we might need their services much sooner than that.

Thanks.

 

[ecmst12]

Is your insurance through your employer, or your spouse's employer? If so, is it a self funded plan? If so, any state regulations that DO exist would not be enforceable on a self funded plan. Most employer-sponsored insurance plans are self-funded, except for very small companies.

Either way, I doubt there are any such regulations. It would be up to your insurance policy. Some policies have a provision such as the one you describe, and some don't. Your plan is a PPO, which means that even if you see out of network doctors, you still get partial coverage, and you have a yearly maximum out of pocket cost, so the policy may take the position that such a provision isn't needed - after all, it's not like they're DENYING the bills. But if THEY have to pay more for a non-contracted doctor, then YOU should have to share part of that higher cost by paying a higher percentage for services. Insurance is a business after all.

Have you spoken to customer service about this situation yet?

 

[cbg]

I've been working with health insurance plans for 27 years and I've never heard of such a regulation. I've not done a lot of work in OK, though, so consult the state Department of Insurance (the Department of Health would not be the regulatory agency in this case) for a definite answer.

 

[FLMommy]

Thanks to the both of you.

It is self-funded as far as I know. Yeah, talked to cust service - they went through the whole thing about referring healthcare providers, - that process takes forever.

Anyways, things have a 'funny way' of always working out in the end for us - my husband contacted his corporate office, and was informed that when we moved, we should have been switched to a different PPO (but same insurance). That PPO does not cover this hospital/dr eiter, so corp told him to call the dr's office, ask what PPO's they do accept, and call them back. Then corp called the insurance company, and told them to pick one of those PPO's. Basically, his company is switching us to a different PPO (but same insurance) that DOES contract with this Children's Hospital and this dr.

I guess that is highly unusual, but it works for us

Thanks again for your time, I know you both always some good input.