For many patients, seeing a specialist may take months, even with a referral. For others, there may be no specialists in a patient’s plan. If one were to call the insurance company for assistance, they likely would be given several names in-net work, only for the patient to find that the specialist is no longer in-network. Evidence shows that many HIV clinicians often treat diseases they think would be better managed by a specialist. According to a study published in AIDS Care, 75% of HIV clinicians treating people with HIV acted as their primary care physician. That is not good for the doctor or the patient.
Many patients need a specialist, whether there are any in their plan or not. What can physicians do when they can’t find a specialist for a patient?
Ask the patient to talk to their HR department. HR employees may have experience dealing with health insurance companies and can assist in making things happen.
Ask for coverage to see an out-of-network specialist. This is the law. However, not every employee at an insurance company knows this and may need to be reminded. Further, don’t just send a letter of medical necessity, as most insurance companies will not react. Each health insurance company has its own appeal process; if it is not followed, people can be denied.
Call the insurance commissioner. The state insurance commissioner’s job is to ensure that insurance companies follow state laws and do not endanger lives.
Contact the charity department at the local hospital. They can sometimes connect the patient with a specialist who will see them free of charge. Knowing what a patient needs and not being able to give it to them is a frustrating experience. A physician’s job is to treat patients. The US has the best medical care in the world; however, it is not available to everyone. Unless you have the “right” insurance, shortcuts will be made to stay in the health insurance coverage zone, which seems to be shrinking daily. With skyrocketing costs of medical care, few can afford to pay outside their coverage. Currently, the healthcare system is headed for disaster, and doctors have little that can change the system; they need others to get involved in reform to change patients’ lives.
