Aa
out of state coverage
I am 35 year old female. Have rare brain disease called Chiari I malformation. Have Medical Mutual of Ohio and it gives us 100 percent coverage. I have had 2 brain surgeries and 1 spinal cord surgery and am severely ill possilbly needing 3rd brain surgery. I see a surgeon at the chiari institute in new york. I have gone to every local doctor but because new york did my most recent surgery no one will even consult with me. My insurance said it is out of state therefore I will be responsible for bills or back bills if they do cover part. Is this legal given the fact that I have been refused to even meet with doctors under the plan? There are no other options for me but to go out of state for help. We pay close to 1000 dollars for coverage and to potentially be billed because it is out of state and the plans doctors won't even review my films, seems not right. What can I do?
MEDICAL PROFESSIONAL
Dear krisit333,
If you have a PPO plan, your out of network services (regardless of in or out of state) are usually subject to review & if approved will be paid at lower rates.
When you use a in-network provider, you & your insurer are protected through a pre-negotiated contract that has pre-determined fees for all kinds of services. This contract prevents the provider from balance billing or over-charging you and your insurer!
When you go to the out of network provider, you and your insurer loose that protection, so insurance companies do all they can to encourage you to use an in-network provider.
Having said that it seems like your insurer has already paid for 1 surgery that was performed in NY, so it is not clear why they approved that part of your treatment & not the rest!
Sincerely,
Amir Mostafaie
If you have a PPO plan, your out of network services (regardless of in or out of state) are usually subject to review & if approved will be paid at lower rates.
When you use a in-network provider, you & your insurer are protected through a pre-negotiated contract that has pre-determined fees for all kinds of services. This contract prevents the provider from balance billing or over-charging you and your insurer!
When you go to the out of network provider, you and your insurer loose that protection, so insurance companies do all they can to encourage you to use an in-network provider.
Having said that it seems like your insurer has already paid for 1 surgery that was performed in NY, so it is not clear why they approved that part of your treatment & not the rest!
Sincerely,
Amir Mostafaie
Thank you for your response. Actually we had different insurance at the time of my previous New York surgery. Our prior insurance was very helpful due to the fact we had everything documented that no one else was able to help. Since we switched insurances, not by choice of course, the new group is saying it is out of network and so on. My question is if their own in network groups are refusing to see me, shouldn't they be responsible for the bill if I need another rare brain surgery and can't find help anywhere else in network. I also understand it will be under review and am hoping for the best if and when it comes to that. Thanks again.
Sincerely,
Kristi
Sincerely,
Kristi
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