Does it normally take a week to hear back re: insurance's out-of-network benefits for prospective new psychiatrist I'd like to set appt. with?

[omotayo]

I'm new to my university's insurance plan. It's underwritten by a company Wellfleet and follows the Cigna PPO network to determine in-network vs. out-of-network providers. That said, they generally encourage students to see providers through out university's student health clinic, where there are also psychiatrists or psychiatric nurse practitioners there.

However, mental health services do not require a referral to see someone out-of-network. And I thought my plan was pretty simple in that in-network specialist (e.g. psychiatrist) visits cost $30 copay/visit then 10% coinsurance, while out-of-network specialist (e.g. psychiatrist) visits cost 40% coinsurance.

The specific out-of-network psychiatrist I want to see has a large research and clinical background in my specific psychiatric diagnosis/issues, hence my preference.

I called his office last week, was told he's out-of-network for my plan, I said that was fine, was even told his full out-of-pocket rates and was surprised they were relatively affordable, and gave all my insurance information.

I checked in today and the secretary said she hadn't forgotten about me, sent out the insurance information, and was waiting to hear back about my out-of-network benefits.

Did I miss something when I reviewed the plan's 70-page brochure and highlighted the part saying "in-network psychiatrist visits are $30 copay then 10% coinsurance, out-of-network psychiatrist visits cost 40% coinsurance, & no referral is needed to see an out-of-network psychiatrist"?

Maybe I've been spoiled but all my insurance plans up to this point? I'm used to instantaneous coverage benefits checks—approved w/ X, Y, Z costs falling on the patient, or a simple rejection.

So confused.

 

[resjudicata]

@omotayo I don't know what's taking them so long, providers can immediately run benefits through Cigna's web portal or can call in for them.

However, I would not be surprised if your out of network benefits are 40% coinsurance AFTER your out of network deductible is met, which is going to be considerably higher than your in network deductible. In addition, Cigna will only credit what the "in network allowed amount" would've been towards that deductible and you still may be billed for the full amount of the visit.

I know the desired provider has a specialty that's helpful for you, it may be of benefit to do your research to find out if there's an in network doctor in your area that has similar education or can perform the same therapy, this is the most cost-efficient plan. If you can't find a provider like that, talk to Cigna to see if they can come to an agreement with your desired provider so Cigna can process the claims as participating.

Or agree on cash rates if you can afford it and submit after for credit to your out of network deductible. Or pay the full amount of the visit. It's just very unlikely that you're going to be paying 40% coinsurance right out the gate.

 

[omotayo]

@resjudicata Thank you. This is helpful. I actually was contacted by a case manager who is also a mental health counselor. I think she is contracted by Wellfleet, but not directly their employee (as case managers for insurance companies in my experience are often in-house?). Anyway, she was sympathetic to my psychiatric situation in general, and she offered for me to relay her contact information in regards to a group therapy program I was trying to enroll in (which was what I believe prompted Wellfleet to have her reach out to me).

I feel bad asking her to get involved here, too, because she's very nice and seems sympathetic to the extra leg work I'm doing while also trying to manager my health being not where it usually is, so I feel like I'm taking advantage of her kindness.

Anyway, I think there is a LOT more than what meets the eye. I feel like the psychiatrist's practice/billing folks are also benefiting from the delay/stalled time. Because I more or less implied today that I would be able to pay out of pocket while the insurance is getting sorted it out (and in reality, his rates are "below the going rate" based on what I was *told* his out of pocket costs are). The thing is, my impression was not that they opted to continue waiting on the insurance in order to spare me having to pay out of pocket...idk...I guess starting tomorrow I need to start being pushy. I always say there's no way I can outsmart all these insurance people, but I sure as hell don't want their BS time wasting to interfere with my health.

Thanks again, I'm gonna revisit your post tomorrow so I heed your advice even more when I get up tomorrow and get a chance to follow up on this.

 

[omotayo]

@resjudicata

If you can't find a provider like that, talk to Cigna to see if they can come to an agreement with your desired provider so Cigna can process the claims as participating.

Or agree on cash rates if you can afford it and submit after for credit to your out of network deductible. Or pay the full amount of the visit. It's just very unlikely that you're going to be paying 40% coinsurance right out the gate.

Again, thanks for these tips. My reply got a little ranty, but I'm refocused and gonna heed your advice.

 

[resjudicata]

@omotayo You're all good, it's confusing! You can look up your benefits too either online or by calling. I'd like to assume they're not stalling for their own delay. If they're delaying, it's not bringing money in, so you think they'd be on top of things!

And absolutely use the case manager, that's that they're supposed to do for you!

 

[omotayo]

@resjudicata Welp, just called insurance...looks like the doc's office was actually the one slow in sending out the insurance info while the insurance actually responded in a reasonable turnaround.

 

[omotayo]

Update: slow doctor's office, not slow insurance office (this time...)