Last winter I had a bad case of the “flu,” and called my family physician’s
office for an appointment. (He is the preferred provider under the PHN
insurance.) The answering service referred me to another office, as my
physician was on vacation that week.
Unfortunately, the office to which I was referred is NOT a PHN participant.
PHN has refused to cover their charges, claiming that I went outside their
My question: Is this the standard practice for PPO-type health insurance
companies? What do they expect sick patients to do when their preferred
providers are on vacation — wait for them to return?
Insurance companies will do all they can do to NOT pay anyone for
anything. If they are presented with a loophole, they will be through
it in the blink of an eye. The managed care companies are the absolute
worst (HMO, PPO, Capitation). The insurance companies always push
themselves as having this great compassion for quality care for their
policy holders, but the bottom line is all that really matters to them
and they prove that point over and over again. If you keep pushing and
writing letters to your insurance company and let them know you will be
sending copies of these letters to the insurance commissioner in your
state, you will probably get re-imbursed. But you have to be willing
to really duke it out with them because they will drag you along and
hope you get tired of fooling with it.
Or ask the physician to whom you are referred, whether they are
on the list of PPO’s to which you subscribe. If not, go back to the
person who referred you and tell them to refer you to someone who
can help you through your PPO.
Don’t trust anyone, especially an answering service.
Dont look in the “big book”. More than likely, the doctors listed
there are no longer enrolled.