Health insurance benefits are meant to cover the costs of necessary healthcare in the event of illness or injury. But what if your limited health insurance provider network makes the benefits impossible to obtain?
More and more often we are seeing health insurance policies which have insufficient provider networks. If a health insurance policy provides benefits to diagnose or treat the patient’s condition then it must also identify an in-network provider appropriate for the patient’s condition. This scenario plays out when health insurance companies have inadequate provider networks for specific specialties such as surgical specialists, neurologists, or mental health providers.
Without a sufficient provider network, it can be impossible to access provider benefits and patients are forced to seek healthcare from out-of-network providers. A patient gets no certainty, no assurance, and certainly no comfort from a policy which cannot be used for the patient’s needs.
Provider networks have become more restrictive. https://avalere.com/press-releases/health-plans-with-more-restrictive-provider-networks-continue-to-dominate-the-exchange-market. Federal law has protections against inadequate networks. The Affordable Care Act requires health insurance companies or health plans to have a provider network that is “sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to ensure that all services will be accessible without unreasonable delay.” 45 C.F.R. § 156.230 (a)(1(ii).
If your insurance network does not have a sufficient number and types of available providers, your benefits become inaccessible. You can challenge a provider network by documenting your telephone calls to in-network providers and asking if they are available to take new patients, are willing to treat your condition, etc.
Write to the insurance company with the information you obtained and request benefits for an out-of-network provider at the in-network rate. If the insurance company denies your request, you can appeal. Make the most out of your health benefits by challenging what is not working properly in the health insurance system.
At Kantor & Kantor, LLP, our attorneys have the in-depth knowledge and legal expertise to help you when your request is denied, disputed, or delayed. Our consultations are free and we work on a contingency fee basis for most of our cases. Time is of the essence, so don’t delay getting started by completing our online contact form or calling our law firm today. Let us help you.
