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Getting or keeping an out-of-network doctor

Insurance companies, health maintenance organizations, and managed care organizations, including MassHealth insurers, have networks (or lists) of doctors, therapists, hospitals, and other mental health providers for whom the insurance companies will pay.

What happens when the therapist or doctor you want is not part of the insurer's network of providers?

  • Check your policy to see if you have an out-of-network option. If you do, you may have to pay a higher co-payment to see an out-of-network doctor than if you see an in-network doctor - but at least you won't have to fight the insurance company over whom you can see.

If you don't have an out-of-network option:

  • Ask your provider to join the insurance company's network (sometimes called "panel") of providers.

This takes time and your provider may not want to agree to the insurer's terms, including requests for paperwork.

  • Ask the insurance company to pay your doctor, even if she is not part of their network of providers.

When you ask the insurance company, you should know two things:

  • The insurance company is unlikely to pay an out-of-network provider if she won't accept the same rate of payment that in-network providers get. Check with your doctor to make sure she'll accept the insurance company rate, which is usually lower than what people pay out-of-pocket.

  • You should be able to explain why it is MEDICALLY NECESSARY for you to see this particular doctor or therapist. The definition of medical necessity varies with each insurance company.

Proving medical necessity

Here are some things that might show that seeing a particular doctor is medically necessary:

  • There is no other doctor/therapist in the insurance company's network who has the same expertise. Specific expertise is especially necessary for children or if you have a complicated or rare diagnosis.
  • There is no available in-network doctor/therapist within a reasonable distance from your home. Insurance companies often claim that clinicians are available when, in fact, they are not taking new patients.
  • You have developed a trusting relationship with the doctor/therapist. If you have been seeing a clinician for a very long time, it may cause you to lose ground and get worse if you are forced to stop seeing your doctor/therapist. If you've finally formed a bond with a therapist or doctor, you may be able to keep seeing that clinician, even if you haven't been with the clinician for a long time. It helps if you can show a history of failed attempts to find a doctor/therapist who works for you. Whether you've been seeing the clinician for a long or a short time, in both cases, continuity of care with the out-of-network provider is medically necessary for you.

Tips:

  • Be sure to get a list of in-network providers from the insurance company.
  • Call a reasonable number of doctors/therapists (5 or so) to see if they have the expertise you need, can see you within a reasonable period of time, and are close enough to your home or work.
  • Keep a written record of whom you call, the dates, to whom you talked, and what they said.
  • If none on the list satisfies your needs, call the insurance company, let the insurer know you've made enough calls, and ask the company to find you someone who fits your needs.
  • If they don't find someone who fits your needs, ask them to pay for the out-of-network provider.

If you ask for out-of-network authorization due to medical necessity and the insurance company refuses to give you the ok to see an out-of-network clinician, the insurer must give you a denial notice and tell you about your right to appeal the decision.

If you have a new private insurance policy, and your current doctor or other clinician is not covered by the new insurance policy, you can keep that clinician for 30 days if:

  1. Your doctor is not in the network of any of the insurance companies offered by your employer;
  2. The clinician is willing to accept the rate of payment to network clinicians and won't charge you more than if she were a network clinician;
  3. The clinician is willing to accept the "paperwork" requirements of the insurance company; and
  4. You are in on-going treatment with this clinician.

For further advice and help on keeping your current mental health provider or on getting insurance/MassHealth payment for an out-of-network mental health provider, call Mental Health Legal Advisors Committee, 617-338-2345 ext. 29.

Produced by Mental Health Legal Advisors Committee
Last Updated July 7, 2009

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