What If You Need an Out-of-Network Provider?

Is the Provider Network of Your Insurance Company Inadequate?

When You Need Treatment from an Out-of-Network Provider

Health insurance companies want you to use in-network providers. This is because insurance companies have negotiated contracts with these providers which are favorable to insurance companies.  In short, these providers have agreed to accept lower payment for their services in the hope that they will get a higher volume of patients. When you use an in-network provider, it allows insurers to optimize their profits and minimize their costs.

Sometimes using an in-network provider may be acceptable to you.  But sometimes the insurance company does not have an in-network provider who is qualified to provide the treatment you need. It is a sad reality for too many that health insurance companies often reject coverage for medical treatments administered by physicians who aren’t part of their established network. That common practice is well known, because the phrase “out-of-network provider” is familiar to most of us.

When you face out-of-network denials, count on support from Kantor & Kantor. We will fight to get the out-of-network medical procedure you need. Contact us at 818-886-2525 for your free consultation.

That List of Providers Aren’t Actually Available to Help You

How Your Insurance Company May Have a “Ghost Network”

Most policyholders don’t know about a problem with lists of in-network providers made available by insurance companies. This problem is especially pervasive when it comes to mental health providers. However, our team at Kantor & Kantor are well aware of the issue. Perhaps you need medical treatment from a specialist and, to get help, you turn to your trusted list of in-network providers your insurer makes available. You begin to make some calls to set up an appointment.

After reaching out to a few, you may start to feel frustrated. But you persist and make more and more calls. You find that some are not accepting new patients, others have moved, and others still do not have the special skills you need. This lengthy, frustrating time spent making call after call reveals a hidden truth: the providers in the list aren’t actually available to you. This is called a “ghost network.”

Now what? How do you get specialized medical treatment when no doctors capable of providing it are in-network?

At this point, you have to resort to out-of-network providers to seek medical care. If you’re lucky, your insurance company will establish an agreement with that provider to set a fee they will offer, and the provider will accept. However, many times insurance companies refuse to offer a reasonable fee to your chosen provider, and you are stuck paying out of pocket or going without treatment.

If you face this frustrating situation, call our team at Kantor & Kantor to work with your insurer. One of our founding partners, attorney Lisa Kantor, provides extremely helpful information to policyholders in her video series about Health Insurance FAQs. In this video, she speaks in detail about “ghost networks” and what to do about them. Our team has assisted many clients who find themselves in this predicament. Depend on our knowledge.

Why Choose Kantor & Kantor?

Our Winning Strategy Has Helped Thousands of Policyholders

At Kantor & Kantor, we understand the frustration and uncertainty that can arise when your insurance company denies coverage for out-of-network medical treatments. We also know many insurers pad their list of in-network providers, giving policyholders the impression that they have many choices when sometimes they have little to none. This is true not only for niche specialists but also for more commonly used practitioners, like mental health providers.

Our law firm has built a strong reputation as dedicated advocates for individuals facing insurance denials, particularly with respect to  out-of-network coverage. We are people helping people, and we will fight to get you the coverage you need.

Here’s why choosing an insurance lawyer at Kantor & Kantor can make all the difference in your legal fight for access to providers your insurer will pay for:

• Expertise and specialization: Our firm focuses on insurance denials, including  out-of-network coverage cases. We have an exceptional track record of successfully representing clients when insurance companies have wrongfully denied coverage for essential medical treatments. This specialization allows us to bring a deep understanding of the intricacies of insurance law to each case we handle.
• Extensive resources: We have a team of skilled, inadequate-network lawyers with diverse legal backgrounds and a collective wealth of knowledge in insurance law. This allows us to effectively approach your out-of-network coverage denial case from multiple angles, exploring innovative solutions and strategies to counter the insurance company’s arguments.
• Client-centered philosophy: Facing an insurance denial can be emotionally and financially taxing. At Kantor & Kantor, you’re not just another case number – you’re a valued client. We understand the emotional and financial toll that out-of-network coverage denials can have on individuals and families. Our client-centered philosophy means that we prioritize your needs, concerns, and goals throughout the legal process.
• Skilled negotiation and litigation: Our lawyers are skilled negotiators who strive to achieve fair settlements through communication and diplomacy. However, we are fully prepared to take your case to court if negotiations prove ineffective. Our litigation prowess ensures that your case will be aggressively argued in any setting.

What Our California Inadequate Network Attorney Can Do

When you’re hit with an out-of-network coverage denial, it can feel frustrating and overwhelming. That’s where our experienced California inadequate network attorneys come in. We are people helping people, and we’re here to be your voice and fight for your rights.

Insurance policies can be complex and filled with confusing jargon and fine print. Our team has a knack for dissecting these documents, ensuring you understand what you’re entitled to and why your claim was denied.

• Build a solid case: Armed with a strong understanding of medical procedures and insurance practices, our attorney will craft a compelling case to challenge the denial. We collaborate with medical professionals to gather evidence that proves the medical necessity of the out-of-network treatment you require.
• Talk the talk: Negotiating with insurance companies can be like speaking a different language. Our attorneys are fluent in insurance jargon and understand insurance company tactics. We’ll directly negotiate on your behalf, using our expertise to fight for your rightful coverage.
• Taking it to the next level – going to trial: If negotiation doesn’t yield the results we want, we’re ready to escalate the situation. Our attorneys are seasoned litigators, experienced in taking cases to court. We won’t back down from a fight, especially when it’s about your health and financial well-being. We’ll present your case confidently and aggressively in court if that’s what it takes to achieve justice.
• Your rights are our priority: At Kantor & Kantor, we firmly believe that coverage denials should never compromise your access to necessary health care. Our attorneys are dedicated to standing up for your rights and ensuring that you’re not left shouldering hefty medical bills due to insurance company decisions.

Do you have questions or concerns? Our attorneys with advanced knowledge of inadequate provider networks are here to answer your concerns and guide you through the process.

Is Your Health Insurance Through Your Employer?

When your health insurance is provided through your employer, it’s often governed by a set of rules called ERISA, which stands for the Employee Retirement Income Security Act. ERISA  sets the guidelines for managing health insurance coverage and what needs to be done to protect your rights as a policyholder. It spells out things like how the plan should be funded, how information should be shared with you, and what to do if you need to appeal a denied claim.

While we refer to “insurance policies” as we discuss coverage by your insurance company, the terms specific to insurance governed under ERISA are “plans” with a “plan administrator” who oversees decisions about your policy coverage.

The ERISA Appeals Process

When your insurance company denies a claim for an out-of-network specialist under an employer-sponsored plan, the steps you can take are fairly similar to those with regular insurance policies. There is one particular difference: You cannot take your case to court unless you have gone through the appeals process first. Because ERISA laws are inherently complex, you need to work with an ERISA attorney who understands these federal rules in detail. You’ll find that expertise in our ERISA attorneys who can guide you through appeals, ensuring your rights are upheld.

Did You Think Your Provider Was In-Network?

… But Found Out They Were Not.

A 2015 survey by Consumer Reports unveiled that nearly one in four California patients who underwent medical procedures or sought health care services within the preceding two years received bills reflecting out-of-network rates although they believed the providers were in-network¹. Such instances frequently arise when patients undergo care that involves hospitalization or surgery.

However, recent legislation²  offers added protection for people living in California who have individual health insurance plans overseen by the state Department of Managed Health Care (DMHC) or the California State Department of Insurance³. This covers around 70 percent of privately held health insurance policies in the state, as cited by the California Health Care Foundation.

If your insurance claim was denied due to care being given by an out-of-network provider, you might find grounds to appeal. In such circumstances, seek guidance from a California attorney for inadequate provider networks. Our lawyers can help you chart a course that maximizes your chance of securing compensation for your treatment – even when it is with an out-of-network provider.

You may be able to fight for out-of-network coverage at a reasonable cost. Turn to our highly experienced insurance attorneys for help. Contact our Kantor & Kantor team at 818-886-2525

What Is Out-of-Network Coverage?

Health insurance companies maintain a designated network of medical facilities, hospitals, and various health care service providers. These entities are health care providers with whom the insurance company has a formal business arrangement. Within these networks, insurance carriers and health care providers establish contractual agreements for services, often at a discounted rate. Policyholders are entitled to receive medical services from these providers as outlined in their insurance policies and can expect coverage for the costs, after deductibles, copayments and/or co-insurance.

Many insurance policies stipulate that policyholders must seek medical care exclusively from health care providers within their designated network to get coverage. These types of policies are generally called HMOs (Health Maintenance Organizations). Under an HMO, patients are generally not free to choose any doctor that suits their preferences. Their options are often constrained to a smaller selection of physicians covered by their specific insurance company and policy.

When a patient with an HMO seeks medical care from a doctor outside the insurer’s network, the insurer must create an agreement with that single provider before the patient can obtain treatment. The company might request a reduced treatment payment. If a fee cannot be agreed upon, the insurer may decline coverage altogether.

Insurers avoid working with out-of-network providers due to the absence of an established, agreed-upon fee schedule. These providers are frequently out-of-network precisely because they have not agreed to render services at a reduced rate.

However, the necessity for medical assistance from an out-of-network provider does not automatically grant insurers the right to deny coverage across all scenarios.

Specialties and Network Limitations

Certain medical specialties may pose unique challenges within the context of in-network and out-of-network coverage. These challenges arise due to factors such as specialized training, limited availability of practitioners, and the necessity for specific equipment or facilities. As a result, policyholders seeking care from specialists may encounter difficulties when those specialists are not included in their insurance network.

Why Some Specialties are Out-of-Network

Expertise and Training

Specialized medical fields often require practitioners to undergo extensive training and education. This can lead to a limited number of specialists in a given area, making it more likely that policyholders will need to seek care from out-of-network providers.

Unique Services

Certain specialties require access to specialized equipment or facilities that may not be readily available within an insurance network. This can lead policyholders to seek treatment from out-of-network providers who can offer the required services.

Geographic Limitations

In some regions, specific medical specialties may be less available, necessitating out-of-network providers for individuals requiring specialized care.

When Should Out-of-Network Claims Be Covered?

There are situations in which insurance companies should cover the costs of medical services, irrespective of whether the health care provider is in-network or out-of-network. Several scenarios demand medical attention that might not be available through in-network providers.

Instances that warrant insurers covering care, regardless of provider network, include:

Emergency services: If a policyholder needs urgent medical attention due to an accident or emergency, they might not have the luxury of selecting an in-network provider. This situation could arise when the patient is out of state or when waiting for an in-network provider is impractical or unsafe. Emergency medical services are typically exempt from network restrictions.

Specialized care: The network of medical providers within an insurer’s coverage might be limited. If a policyholder requires specialized treatment unavailable from any in-network physicians, they may seek care outside the network. For instance, a policyholder might need a unique form of heart surgery that no in-network doctor can perform. Or perhaps they need mental health services from a provider specializing in eating disorders and none are available in the insurer’s network.

In such cases, policyholders can request pre-approval from the insurer for out-of-network treatment with potential reimbursement. With an HMO,  the insurer may require a referral from an in-network doctor before granting approval. Should the insurer deny out-of-network treatment necessary for medical reasons, this could serve as a basis for appeal.

Existing doctor-patient relationships: Many insurers permit patients to continue treatment with a doctor with whom they have an established relationship, provided they have prior approval. It’s best to obtain this approval before seeking treatment.

If you find yourself in any of these situations, yet your insurance company denies payment for treatment you have received or hope to receive from an out-of-network provider, we can help. We are well-versed in state and federal insurance laws that apply in these situations and have experience helping other clients who require out-of-network care.

Don’t delay the treatment you need and the insurance coverage you deserve. Contact our attorneys at Kantor & Kantor.  Call 818-886-2525 to speak with us today.

How Can I Get Necessary Care When the Right Provider Is Not in My Network?

Too often, people have health care needs that cannot be met by their insurer’s network. When you find yourself in this predicament, there are ways to confront this problem to get the treatment you need. You may be able to succeed with the simple steps we list below., Here are steps you can take to navigate this situation and still get the necessary care you need:

1. Review Your Policy

Start by thoroughly reviewing your insurance policy. Understand what it says about out-of-network coverage and any exceptions or provisions for special circumstances. This will give you a clear picture of what you’re dealing with.

2. Explore Your Options

Contact your insurance company and explain your situation. Sometimes, they can make exceptions or provide guidance on how to proceed. They might have a process for getting out-of-network care approved in certain cases, especially if it’s a matter of receiving specialized treatment that’s not available in-network.

3. Request Prior Authorization

Some insurance policies require prior authorization for out-of-network care. If this is the case, work closely with your health care provider to gather all the necessary medical records and documentation to support the need for the specific treatment.

4. Seek Your Doctor’s Help

If your current doctor recommends a specific out-of-network specialist, they might be willing to advocate for you. Sometimes, a doctor’s recommendation can carry weight with your insurance company, and they might be more likely to consider covering the treatment.

5. Explore Legal Support

While it is ideal that one or more of the above steps obtains insurance coverage for treatment from an out-of-network provider, that doesn’t happen for everyone. Insurers are in business to make a profit. It is in their financial interests to limit you to their network of providers with which they have an agreed-upon fee schedule. If you’re facing a complex situation or hitting roadblocks with your insurance company, our attorneys can help. Contact our inadequate network lawyers. We can help you understand your rights, navigate the legal aspects of your need for medical treatment, and advocate on your behalf.

What If My Insurance Company Denies a Claim for an Out-of-Network Specialist?

Dealing with a denied insurance claim can be frustrating, especially when a specialist is not in your insurance network. However, there are several steps you can take to address this situation and potentially overturn the denial:

• Understand the denial reason: First, carefully read your insurance company’s denial letter. They should provide a reason for the denial. It might be about medical necessity, lack of authorization, or simply that the specialist is out of network.
• Reach out to your doctor: Talk to your doctor or the specialist who recommended the treatment. They might be able to provide more information or help you understand why they believe this particular treatment is necessary for your health.
• Gather documentation: Gather all the documentation related to your case. This includes medical records, test results, doctor’s notes, and any communication you’ve had with the insurance company. This paperwork will be crucial when appealing the denial.
• Initiate an appeal: Most insurance companies allow you to appeal a denial. This means you’re asking them to review your case again. Follow the instructions in the denial letter and the policy to start the appeals process. Ensure you include all your documentation and any additional information you’ve gathered.
• Contact an attorney with experience in out-of-network cases: If you’re hitting a dead end with your insurance company, you might want to seek help from a legal expert. Our California inadequate network attorneys can guide you through the process, as we have with many clients before you. Trust in our experience. We’ll battle your insurer on your behalf to help you get care from the medical provider you need.

You need representation from an attorney who is experienced with out-of-network coverage cases. At Kantor & Kantor, that’s just what you’ll find. Our compassionate attorneys understand you’re in a frustrating, if not frightening, situation. We’re ready to assist you now.

We are people helping people, and we want to help you. Give us a call at 818-886-2525 to talk about your case.

Inadequate Network FAQs

Can I negotiate with an out-of-network provider to lower costs?

Yes, you can try negotiating with an out-of-network provider. Some are open to offering discounts or payment plans, especially if you explain your situation and financial limitations.

How long does the appeals process usually take?

The appeals process duration can vary. It often involves several rounds of communication, documentation, and review. Some appeals may be resolved within a few weeks, while others could take longer.

What if my insurance company claims the treatment isn’t medically necessary?

If your insurer denies coverage based on a lack of medical necessity, you can provide additional medical documentation and expert opinions to support your claim. Your doctor’s input can be crucial in these cases.

What if the insurance company still denies my claim after an appeal?

If the appeal process doesn’t yield a favorable result, our attorneys can guide you through further legal options, such as litigation, to escalate the matter.

What To Do When You Need Out-of-Network Treatment

Get Help from Our Inadequate Network Attorney Today

If you face an out-of-network coverage denial, don’t navigate the complex legal waters alone. Turn to Kantor & Kantor for help. Your health and well-being are our top priorities, and we are ready to stand by your side throughout this challenging journey. You can depend on our experience and our detailed knowledge of insurance law. You can also depend on our compassion for your frustrating situation. We understand what you’re going through and we’re here to help you get the treatment you need from the type of provider you need. Give us a call at 818-886-2525 to schedule your free consultation.

Sources

¹ Consumer Reports. Californians face out-of-network bills, don’t know where to turn for help. https://advocacy.consumerreports.org/wp-content/uploads/2015/05/Surprise-Bills-Survey-CA.pdf

² California Legislative Information. AB-72 Health care coverage: out-of-network coverage. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB72

³ Department of Managed Healthcare. Independent Medical Review & Complaint Process. https://www.dmhc.ca.gov/FileaComplaint.aspx

Attorney Glenn R. Kantor

Glenn Kantor is a founding partner of Kantor & Kantor LLP. As a young attorney, Glenn saw the injustice of wrongful insurance denials and created a law firm to represent individuals seeking to obtain their rightful benefits. Glenn is committed to ensure that clients receive the benefits they are entitled to under their insurance policies or group health plans. [Attorney Bio]