In-network Provider Compliance

[Browny]

Texas

My in-network provider is refusing to order an injectable medication that must be administered in their office. The medicine is covered under my medical benefits if the doctor's office orders it since it will be administered in the office. It is not covered under my prescription plan so if I have the prescription filled, my insurance company will not cover it. I have contacted a 2nd in-network provider and they too refuse to order the medication because it is pretty high priced and the insurance company is only willing to pay them the "in-network" cost for it when the provider files the claim. I asked the insurance company to help me find a provider who will comply with their requirement but they advised there is nothing they can do. I have filed a grievance with the insurance company against 1 of the doctor's office but in the meantime, I am not receiving my much needed treatment. How can I get insurance company to get my doctor's office to comply?

Some Clarifications
The injection is a medication - not a vaccine. My doctor provided me with a letter of medical necessity for the injection because she feels this is the best way to approach the condition. I got a 2nd opinion and the recommendation was the same.

It is common for insurance companies to pay a reduced amount when paying for claims from in-network physicians. This is understood by the physician who agrees to be part of the network. This also applies to medications the physician gives to patients.

The doctor originally wrote a prescription for the medication. I was to go to a pharmacy (monthly) that carried the medication, have it filled and then bring it to the doctor's office to have it injected. The insurance company maintains that it is covered under medical benefits because it must be administered by a healthcare professional. They will not pay a dime if I purchase the medication myself. They will pay the contracted rate to the physician's office if they order the medication and file the claim.


Thanks for the in-network home healthcare recommendation. This is one of the options I will look into.

[moburkes]

Originally Posted by Browny

Texas

My in-network provider is refusing to order an injectable medication that must be administered in their office. The medicine is covered under my medical benefits if the doctor's office orders it since it will be administered in the office. It is not covered under my prescription plan so if I have the prescription filled, my insurance company will not cover it. I have contacted a 2nd in-network provider and they too refuse to order the medication because it is pretty high priced and the insurance company is only willing to pay them the "in-network" cost for it when the provider files the claim. I asked the insurance company to help me find a provider who will comply with their requirement but they advised there is nothing they can do. I have filed a grievance with the insurance company against 1 of the doctor's office but in the meantime, I am not receiving my much needed treatment. How can I get insurance company to get my doctor's office to comply?

Your insurance company cannot order your doctor to comply. By your own words, the cost of the medication is close to or more than what the insurance company will pay for.

[ecmst12]

And, since it is a network provider, they would be forbidden from billing you for the amount over the contracted rate, meaning they would LOSE money by doing this. There is no way they will agree to that, PCP offices make a thin enough profit as it is these days.

[lkc15507]

I am not sure at all that I understand everything in your post. My biggest problem is with the statement that "it" isn't covered under the "prescription" plan if you have the "prescription" fillled. That seems incongrous to me. Injectables often require medical and / or cost overrides from a medical professional within the payer entity. But, I can't quite tell what is happening here since you indicate that the innetwork provider won't order it. I hate to ask anyone to disclose personal health information on a public forum, but if I knew the medication and a little more about the plan, I think I could help. In general, if a medication is delivered in office, that is usually covered under major medical plans. However, bless the pharmaceutical industry, due to the rising, sometimes exorbitant costs of drugs, health plans will require that some medications administered in office be obtained through a PBM (Pharmacy Benefit Manager). The drug could / would still be administered in the physician's office, but obtained through a "prescription". What I am saying is that major medical and prescriptions are often two entirely different "plans" / coverages. In the situation I just described, the PBM would discount the drug and supply the drug, then the medical plan would pay for the cost of the admistration in the physician's office. That arrangement is made because is eliminates the possibility of the physician's office being able to profit on the drug itself. It's also possible that the major medical plan may take the view that the drug, although injectable, is something that the plan participant could self-administer and therefore, they may exclude the cost of the physicians admistration charges. That is why it would be helpful for me to know the actual drug. Some can be self administered safely, some cannot. lkc15507

[momm2500]

have you talked to the insurance company and see if an in-network home health care agency can order the injectible drug and come to your home to administer it? usually their allowance is a little higher. If you do not mind me asking is the drug, Lovenux or another type of med?

[lealea1005]

Originally Posted by Browny

Texas

My in-network provider is refusing to order an injectable medication that must be administered in their office. The medicine is covered under my medical benefits if the doctor's office orders it since it will be administered in the office. It is not covered under my prescription plan so if I have the prescription filled, my insurance company will not cover it. I have contacted a 2nd in-network provider and they too refuse to order the medication because it is pretty high priced and the insurance company is only willing to pay them the "in-network" cost for it when the provider files the claim. I asked the insurance company to help me find a provider who will comply with their requirement but they advised there is nothing they can do. I have filed a grievance with the insurance company against 1 of the doctor's office but in the meantime, I am not receiving my much needed treatment. How can I get insurance company to get my doctor's office to comply?

Other than being exited from that Physician's practice for filing a grievance against him/her, you've accomplished nothing. In network, or not, the insurance company cannot force them to provide a specific service just because it would be covered.

Are you speaking of an actual medication or a vaccine?