My son is afflicted with a very rare form of tumor that none of the doctors in our area has experience with. We participate in managed care insurance through my wife’s employer.
In the process of getting whatever information we could find, we learned that of the 60 or so documented cases of this tumor type roughly half (around 30) have been seen by a team of neurologists at the Mayo clinic. We discussed this with our primary doctor (PCP) and local specialists in Oregon, who agreed with us our son should be seen at the Mayo clinic and proceeded to arrange a referral to that team of neurologists.
The summary plan description for our insurance states:” To receive the plan’s highest level of benefits, you must receive “in-network” care. That means care provided or referred by your PCP or an (company name) designated specialist...” I take this to mean that the process of referral will send us only to an "in network" provider where insurance pays at the highest rate. For the most part our insurance seems to agree with this. They have paid the specialists named on the referral at the best rate.
The problem is anything outside of the actual doctor’s bills is being covered at the out of network percentage. These doctors only have offices inside the Mayo clinic. Any tests or procedures regarding my son’s care are either rejected outright as unwarranted, or paid at the lowest possible rate as out of network. All of the tests were done at the Mayo, which is the facility the “in network” doctors work at.
The end result is we have good coverage for several hundred dollars of doctor consults and minimal coverage for MRIs, body scans, and neurological tests and tens of thousands of dollars of bills that the insurance has rejected all together. Very few specialists have seen our son's condition or anything like it, the doctors who ordered the tests (who we were referred to) insists that the work was needed and have sent a letter for us to try and persuade the insurance.
My questions are:
1. If the referral designates an “in network” provider isn’t it reasonable to assume that the facility they work from (in this case the Mayo clinic) and respective charges are in network also?
2. If #1 has merit, how do we proceed to encourage the insurance company to act in good faith and pay the claims correctly?
This is just the latest and so far most expensive in a string of problems with this company. Reviewing our explanation of benefit advisories and contacting the insurance company has become a part time job for me. At every opportunity they deny, reduce or question validity of coverage, even when claims are straightforward and simple. It seems that we have made it onto their “bad” list and they are hoping that we will go away if they make it miserable enough for us.
Thank you for any help and advice!