Question about health insurance? I've never heard of this??

Question

My bf needs to see a doctor, and we are trying to set up his insurance to see who he can see, etc. Upon contacting the insurance company, we were told that he does not have a PCP, and he can go anywhere that accepts "out-of-network" insurance.

When we asked where he could go, they told us to call around. My insurance company is completely different, and we have called all day and can't find someone to see him.

Does this sound accurate, or did we get a bum representive? Or if you are familiar, can you give us some pointers? We're about to go to the ER for a common problem, and it seems absurd that we can't find a doctor. We don't even know if he would be covered at the ER.

Please help!

Answer 1

Sounds like he has an HMO-you may have some luck still being in network if there is an Urgent Care facility in your neighborhood. Try calling them first. They may even be able to direct you since they have undoubtedly had this situation arise before.

Answer 2

I am no gonna say I am one hundred sure about it.Besides it really depends on the personal feelings.

SO it would better for you to find yourself.Here is a good resource.http://health-insurance.expert-tip.info/...

Answer 3

If your boyfriend has a PPO policy, he would not have a PCP and would simply want to stay with an "in-network" provider.  (not out of network - perhaps you misinterpreted that part?)

If your policy requires you to coordinate care through a PCP, it may be that you have an HMO.  (Or a POS...Point of Service...plan)  An HMO and a PPO are 2 completely different types of policies.  If you have an HMO and your boyfriend has a PPO, that's probably why it seems so different to you.  Its actually more common these days to *not* have a PCP on your policy, as more people are enrolled in PPOs than HMOs.

Your boyfriend's insurance card should contain enough information to figure out whether he has a PPO or an HMO policy.  You should also be able to pull up his provider network on his insurer's website...check to see if there is a Provider Locator website on his insurance card.  (Even if the web address isn't specifically located on the insurance card, most of the time you'll still be able to find a link on his insurer's website anyhow.)

Its not at all unusual for your boyfriend to not be required to have a PCP - I'm in my mid-thirties and have never in my life had an insurance policy that required me to list a PCP.

(Edit to add:  Has your boyfriend received his policy documents yet?  Should be a booklet that could be labeled something like "Summary Plan Document" or "Certificate of Coverage."  That booklet is his contract with the insurance company, and should contain most of the answers to the questions you have.  Granted, the language may be difficult to interpret if you're not familiar with insurance terms, but at least you'd have it in front of you to review and ask for assistance.)

Answer 4

Call 'em back.  They should have a listing of doctors that accept their coverage that they can direct you to.

He would be covered at the ER.  Everyone is for true emergencies, in this case what you could do is go to a clinic, pay for the help and then submit the bill to his company.  It is a pain, but it can work.  Make sure you remember the rule of threes, they will deny you three times before they pay a bill.  80% of all people give up after two tries.

Go to the ER.  You think it it is a real problem, they can't challenge your feeling.  There must also be an emergency number for the national company you have.  Call that one, not just the local company.  

Good Luck.

Answer 5

a) Look in the yellow pages for one of the places that advertises that they will see anyone without an appointment.

b) Go to one of the store front immediate treatment places.  The wait is shorter than an ER and your cost/copay is less.  

Most insurance has at least a $50-500 copay for ER visits even if it is an emergency.  If it is not an emergency, the ER will see you, but you will be billed and the insurance company will not pay.  You may be required to pay the entire bill for going to an ER if it was not a true emergency.  Also, ER's can keep non-emergencies waiting for hours if there are real emergencies.  (They see patients in order of severity, not in order of arrival.)