For many patients, seeing a specialist may take months, even with a referral from a primary care physician. 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-network, only for the patient to find that the specialist is no longer in-network.

Many patients need a specialist, whether there are any in their plan or not. As a primary care doctor, I find this process completely draining, playing out day after day with no relief in sight. Doctors know that patients need to see a specialist, the sooner, the better. They can always call in favors; however, the number of patients outweighs the number of physicians.

What can physicians do when they can’t find a specialist?

Ask the patient to call the insurance company on their behalf. They may not get the answer they want. If physicians speak to more than one agent, they likely will get more than one answer. Patients sometimes have issues locating a specialist, so it is recommended to call multiple providers.

Ask the patient to talk to their HR department. It may be more helpful when the insurance company deals with a whole company that may take its premiums elsewhere. 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 if one is not available. This is the law. However, not every employee at an insurance company knows this and may need to be reminded.

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 not endanger lives. However, politics can come into play here.

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. Rising costs to run practices and stagnant and shrinking reimbursements for more than a decade provided physicians with difficulties. A physician’s job is to treat patients; however, they must still run a business without a loss. Physicians have staff to pay, supplies to purchase, and rent to pay.

Many primary care physicians are often left treating diseases they think would be better managed by a specialist. That is not good for the doctor or the patient. It is just a band-aid solution for the healthcare system.

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.

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Physician’s Weekly | June 6, 2024