Medical Group Madness

Last time, I had a HMO Nightmare. This time around, I suffered through Medical Group Madness. I was finally getting the hang of all the health insurance terms (medical group, primary care physician, specialist, and insurance provider). All my ducks were lined up right? Wrong!

I sauntered to the front desk of my wife’s new OB/GYN. I smuggly looked at my wife and whispered, “I got this”. I explained to the receptionist that my wife was changing OB’s in the middle of pregnancy because we changed insurance companies. She countered, “Where’s your authorization letter from your primary care physician?” I fired back, “I spoke to my insurance provider and they told me pregnancy is the one condition where you don’t need a PCP referral for a specialist.” She blankly answered, “Insurance companies don’t know what they’re talking about.” After some back and forth, we still needed a PCP from the same medical group to authorize our OB’s care.

Since my wife is so far along, I ate the cost. Hopefully we can reconcile at the end, but some things are more important than money. After the routine visit, we hustled over to the PCP office. Thankfully, she was in the same building. Sadly, my wife would need to make a separate trip to see her because she can’t just sign a form and turn it in. How many hoops do we need to jump through? Do we need to set Fire to the Rain? I’m really beginning to burn!

Final Thoughts

Looks like we dodged a bullet as my wife has a new OB, in network. For those of you switching to HMO, make sure your primary care physician and specialist are in the same medical group and are considered in network by your insurance provider. In my opinion, your insurance company is a general guide, but for the finer details of your benefits and coverage, I would lean more on the doctor’s office and the medical group. Everyone’s situation is different so make sure you do your due diligence. Tune in next time when we try and nail down a hospital for maternity services.

What’s your health insurance advice?

Stay Inspired!

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30 Responses

  1. It is really frustrating to deal with a doctor’s office or insurance company. I feel like they have so many different rules and scenarios that are out there to make sure you never get it right. My plan at work has changed every year the last 3 years and it is always a struggle to figure out exactly what has changed about it.

  2. MoneyCone says:

    It is just obnoxious how many hoops we have to go through despite our health care costs being through the roof.

    I’m glad you could work things out without having to resort to what Adele did at the Brit awards yesterday for cutting off her mic! 😉

  3. krantcents says:

    This is one of the reasons I went with a PPO. I am in charge of the decisions. I pay in terms of deductible, but I use my FSA for that.

  4. Some of the things I’m talking about might vary slightly from state to state, but for the most part, these laws are generally applicable:

    1) Women can never be forced to change OBs while pregnant, even if their insurance changes. The new insurance company must pay the old OB, and you don’t have to pay more than your copay.

    2) If the new OB’s office required a letter from your PCP, that has nothing to do with your insurance. Laws require that women’s health care is a specialty that can always be self-referred. The requirement of a letter from her PCP is a requirement of the OB’s office/medical group and should have absolutely nothing to do with your insurance.
    Since you paid out of pocket and shouldn’t have, I would immidiately contact your insurance company about filing an appeal. Depending on your state laws, they may not be able to do anything because they weren’t billed (hello, the new OB just got you to pay at private pay rates, not insurance negotiated rates- a win for them), but they might be able to put pressure on the OB’s office to follow state regulations that (again) say that a woman is always allowed to self-refer for women’s health. Even if the Appeals department can’t do anything, a Member Quality of Care representative should be able to help you.

    These laws were made because we generally believe it is irresponsible to put up roadblocks to pregnant women receiving the care we need. Whether it is forcing insurance companies to pay OBs they aren’t contracted with so that continuity of coverage is maintained, or allowing women to self refer to any OB (within network) without a referral from a PCP so that she has control of her care, it is about making sure women have control of, and are comfortable with, the care they receive during pregnancy.
    In my state, what your wife’s new OB’s office did was illegal. And if that were reported to the insurance company I work for, you can bet our Member Quality of Care representatives would be working to get you reimbursed, and this behavior would reflect negatively on the provider the next time their contract came up for negotiation.

    • Buck Inspire says:

      Thanks Erin for your detailed insight. I know who to turn to for insurance help! Have you ever thought of making a niche site on this? You are quite knowledgeable and passionate about this topic!

      • I’ve worked in healthcare since 1997. With the exception of a 3 year hiatus to do IT work, this is what I do. AND I work for an MCO (like and HMO but moreso). So yeah, I know the laws.
        I believe everyone has the right to caring and effective healthcare and I hate the hoops as much as anyone else, but I also know why they are there.
        I did a series on choosing a Medicare Advantage plan this last fall (as we were signing my MIL up for a new one), but otherwise, no, have not considered doing a niche site for insurance/hmo questions. I’ll have to ponder that.

  5. Buck, I feel your pain. I’m quite sick of the hurdles involved with just seeing a specialist in my HMO. And when you’re stuck being the middle man between the insurance and the doctor’s office, it can result in unexpected side effects like broken teeth and hair loss. You’ll get a confirmation on one side and the other saying it was never received or that it was sent to the wrong person or that the request has expired — I’ve heard it all. The industry has evolved into a money-making machine that quite honestly makes me feel like they prioritize profits over people. I’ll be switching to a PPO very soon, which I know will cost me more, but at least I won’t get any more stress-related migraines!

    • Buck Inspire says:

      Tell me about it. After this nightmare, I’m going to have to visit the doctor to recover! Teeth and hairloss? I’m thinking my stomach lining is all burned away from acid! On a side note, any pick for Edgar vs Henderson?

      • I don’t know too much about Henderson other than one of the greatest kicks of MMA history landed on his face. He’s technical, but Edgar is tough. I think Edgar will grind away at Henderson’s will until he’s gassed and then hopefully G&P a TKO, but more likely by decision.

        Co-main event: I want Rampage to win, but I think this will be pretty evenly matched. Pride Rampage would destroy Bader, but he’s less aggressive these days and playing it too safe. I say Rampage by decision.

        • Buck Inspire says:

          That was an amazing Matrix kick! I really shouldn’t go against you, but to make things interesting I’m going for Henderson and Bader to pull it out. Let’s hope for some exciting fights!

          • David Rodwell says:

            Your wishes came true, Buck. Good calls. Rampage is done, the fire is extinguished. Bader looked great, but considering his height, I think he should move down to middleweight and start dominating down there. Otherwise, Bader and Machida is next.

          • Buck Inspire says:

            Thanks David! Can’t take too much credit, just wanted to make things interesting. With hindsight, I thought Henderson’s height and reach would cause a lot of problems for Edgar. I could imagine Clay Guida having similar success. Edgar should seriously consider dropping to featherweight. As for Bader, credit him for coming back from that nasty body slam. I thought his youth and extra skills would come into play. Rampage does look done. He should just focus on A-Team II!

  6. You’re right, some things ARE more important than money… but that doesn’t make it any less frustrating! It sucks being stuck in the middle.

  7. It can be a real bureaucratic hassle to deal with such medical/insurance issues. When getting non-routine procedures done, seeing a specialist, and changing insurance – it really does pay to do due dilligence. It’s a hassle spending the time, and time isn’t fee. But it can be worth the investment, consdiering how unreasonable some medical costs can be in some cases when not covered.

  8. Ugh, what a mess! I’m sorry you two had to go through that, but I’m happy to hear that it’s working itself out. I’ve never quite understood the need to make an appointment with the PCP when he/she (and you) already know they can’t help you–it’s a waste of their time, your time, money, resources, etc. Set fire to this system, indeed!!! 🙂

  9. What a pain in the butt! I am sorry you went through that. It seems stressful and unnecessary. This just highlights just how complex our health system is. It is quite unfortunate. Oh well. I’m glad things ended just fine, for now!

  10. You are lucky you are able to change ob/gyns. Many ob/gyns do not take on new patients in the middle of a pregnancy.

  11. You know I go to the dentist and he is not covered under my insurance. He is a good dentist, so I stick with him. However, your situation is way and I am not sure what I would have done. Probably I would go through the same thing and mess like you.

    • Buck Inspire says:

      It’s been challenging to say the least. Glad you found a good dentist, did you ever compare pricing with someone who was covered by your insurance? Just curious if you analyzed the gap.

  12. My health insurance advice: hit the gym! I was reading MJ DeMarco’s Millionaire Fastlane and he was mentioning how the beginning of the year is when the gym’s are most crowded, because everyone is making a “committment” to work out. Of course, after two months, most of them have quit. I didn’t believe him when he said this at first, but now I see that this is so true!

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