Doctor Dropped Me

[JenniSam]

What is the name of your state (only U.S. law)? Michigan

Not sure how to handle this situation or if a complaint is even worthwhile.

My issue is with my primary care physician.

I have lupus and a muscle disease (dermatomyositis). I need to see various specialists to get the muscle disease under control. I met with my pcp right away to make sure she was aware and to determine if her office was capable of managing my care. Per my insurance, referrals for a specialists must come from my PCP. My PCP said she would rely on the specialists for direction but that referrals should be no issue. So my rheumatologist leads my treatment plans and my pcp would issue the referrals.

I would arrive for my appointments with the specialists and the referrals would not be done. Sometimes I would have to wait up to 2 hours for them to complete the referral or reschedule the appointments even though I would make the request weeks in advance. I tried calling and putting the requests in writing but the office just would not get them done when requested. I still don’t know why. So I wrote a letter to the doctor asking for her assistance because her staff was not providing acceptable service. I received a certified letter that was 3 sentences long saying “Sorry it did not work out. I will treat you for emergencies only for 30 days. Please let us know where we should send your file.” To be honest I am ok with that. I won’t give you any more business and I started looking for a new PCP.

Here is my dilemma. I set up consultation appointments to find a new pcp, then I had a serious bout with the disease and was hospitalized for 2 weeks. So I had to cancel those appointments and then could not reschedule until October. In the meantime the disease has attacked my muscles so badly that I cannot walk or stand without assistance. So my specialists said I need to see a neurologist and get into physical therapy immediately to combat the damage. Being hospitalized set me back and now I am outside of the 30 days. I have selected a new pcp but he doesn’t take effect for another few weeks. The current pcp will not issue any referrals. I am stuck right now because I have an appointment for the neurologist and physical therapy but no referrals. I don’t want to pay out of pocket for services that should be covered through the insurance that I already pay for. I’ve met my $3000 deductible and I’ve played by the rules.

Is there another approach, angle or avenue I am missing? I am at my wits end and stress is not my friend right now. I want report this doctor who should I file a complaint with? Is it even worth the time to force the issue? A simple referral could save me hundreds of dollars that I don’t have and shouldn’t have to spend or I can risk further damage and wait another 3-4 weeks to see the specialists.

Sorry so long. Thanks in advance for any feedback.What is the name of your state (only U.S. law)?

 

[justalayman]

I would suggest contacting your insurance company and speaking to them.

 

[OHRoadwarrior]

I would also suggest seeing your former PCP and sucking up. I always politely followup to coordinate that referrals have been made. This eliminates the problems you experienced.

 

[JenniSam]

I have contacted the insurance company and they refuse to offer any assistance. I wouldn't expect them to help me utilize the benefits that I pay for even though they should.

Believe me, I've tried the sucking up route and the doctor had the office manager contact me. Last week he agreed to complete the referrals just until my new pcp becomes effective. The new PCP is all set up I just have this silly waiting peroid in the way. I called the current PCP this week to follow up just to be sure the referral is in place for my appointment on Friday. Now he is saying the referrals will not be completed. I just don't get it. I understand I can't make them do anything. Its just so frustrating to need immediate care and to be elligible for the care, but to be denied because of one uncaring doctor.

I wouldn't wish this on anyone. But I wonder how they would feel if they went from being an active 31 year old to needing help just to get out of the bed each day or getting out of a chair. Its cruel for a doctor to leave a patient in such a scary position.

 

[lealea1005]

According to most insurance contracts that require referrals to specialists, the PCP must have documentation of necessity from the specialist before a referral could be issued. This can be as easy as forwarding/faxing a copy of the specialist's office note to the PCP. If contracted with your insurance company, the specialist cannot charge you for the visit/service without that referral being in place.

Having said all that, I'd want to ask OP what reason was given by the CP's office for not getting the referral to the specialist on time. IF all documentation was in place, there is absolutely NO reason your PCP and/or staff could not get that referral to the specialist in time for your visit. S/he is not obliged to give you the referral now that you've been fired from the practice because it is not considered "emergent" treatment.

Unfortunately, your new PCP cannot, legally or contracturally, give you the referral without first establishing you as a patient at his/her office.

Your insurance company is the only entity that could, and IMHO should, override their "rule" in this particular circumstance.

 

[JenniSam]

Lealea1005 - I wish I could answer your question but I've never received a real reason. The only excuse I have ever been given is that the office is busy and gets to requests when they can. I think this office is not capable of handling patients with chronic serious illnesses and that is ok. Just don't tell me you can or will take of things and then when I rely on the office they do not deliver. This disease can and does attack any muscle including my heart, lungs and kidneys. We keep a close eye on them all because I've had complications in the past. I once waited 1 hour for a completed referral to be faxed because the staff was too busy to fax it over to the specialist. I could have paid $200+ up front or wait. It was silly because she argued with me for 20 minutes about how busy they were when she could have faxed it 10 times during the conversation.

My PCP gets a copy of any documentation from specialists and hospitalizations. The documentation to support the need is there.

I also disagree slightly because I consider not walking and daily loss of muscle function an emergent situation. I was hospitalized for almost 2 weeks because of it. My local rheumatologist works with rheumatologists at the University of Michigan and Johns Hopkins because I've declined so rapidly. They completed a 12 page write up that includes testing for my insurance company to approve some emergency treatments. I would think that should be enough for my pcp. I really don't understand it.

After creating this post, I guess I realize that several hundred dollars compared to not walking again is not worth the risk. I will keep the appointments and pay for the visits. It just sucks because I've met my deductible. I am trying so hard to not give up. I pay family members to take me to and from work everyday, I get out of my seat only to use the restroom and I do this all to pay for and keep my health insurance but one doctor is stopping me from utilizing it.

 

[lealea1005]

I will keep the appointments and pay for the visits

I could have paid $200+ up front or wait

Again, (and confirm this with your insurance company) if the specialist is in network or contracted with your insurance company, they are not permitted to charge you for the visit if they do not secure a referral BEFORE the visit. In addition, most insurance companies will not honor retro-active referrals. Your specialists/sub-specialist who contract with your insurance company know this.

 

[You Are Guilty]

Depending on the insurance company, I have had some success contacting their customer support, explaining the issue, and having them generate a short-term referral themselves, cutting the PCP out of the process.

Granted, this is not a viable strategy to use long term, but for a one time "emergency", it might be worth a shot.

 

[JenniSam]

Thank you for all the responses. I appreciate it.

I will not cancel the appointment. But I will continue to try to work with the insurance company right up until I walk in the doctors office.

Thanks again!

 

[ecmst12]

It sounds like what you really need is to switch to an open access type of policy...if that's possible for you at all, DO IT.

 

[JenniSam]

ecmst12: You are correct and I have done that. The problem is the waiting peroid for it to take effect. I called the University to see if I could push my appointment back 1-2 weeks. But if I cancel this appointment I can't get another until the end of November. Because the neurologist is collaborating with the physical therapist, I would have to change the physical therapist appointment as well. I will keep working at it. Thanks!