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Problems getting healthcare referrals

Problems getting healthcare referrals

Old Sep 8th 2014, 8:34 pm
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Default Problems getting healthcare referrals

Our son is autistic and previously on Kaiser Permanente he was getting great help. He's been on medication (not our first choice by any means). Since switching to another provider, because of the wife's job, we've had real problems getting getting the appropriate healthcare.

First problem are the pediatricians. There are only two in the plan and they cover a big population so getting an appointment is one thing, not spending half the day there because they squeeze too many appointments in is another. Equally there are only two psychiatrists in the area and they are not taking on any new patients. After three months of back and forth between the pediatrician and the healthcare provider we eventually got to see a psychiatrist 70 miles away. But apparently that was a one-off and we have to get new authorisation to see him again. He re-prescribed the medication but only for one month. Our son can't just stop the medication, it has to be controlled. Fortunately previously the doctors at KP were kind enough to re-prescribe the meds even though he wasn't a patient any more.

So our son is on controlled medication and can't stop, and the healthcare provider is basically refusing to give him a psychiatrist, out of incompetence/oversubscription rather than refusal as such. Only psychiatrists (at least for this provider) can prescribe the meds We're over 3 months into this mess.

What now? I'm not sure we could afford KP's prices privately.

Last edited by GeoffM; Sep 8th 2014 at 8:43 pm.
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Old Sep 8th 2014, 9:19 pm
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Default Re: Problems getting healthcare referrals

Approach a paediatrician('s office) directly and ask what you would pay out side of going through an insurance company. Some might refuse, but I hear some doctors will take as little as 50% for cash/ credit card settlement compared to dealing with insurance paperwork.
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Old Sep 8th 2014, 10:26 pm
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Default Re: Problems getting healthcare referrals

Originally Posted by Pulaski View Post
Approach a paediatrician('s office) directly and ask what you would pay out side of going through an insurance company. Some might refuse, but I hear some doctors will take as little as 50% for cash/ credit card settlement compared to dealing with insurance paperwork.
Agree with Pulaski.
Definitely worth asking. Although going to a pediatrician just for the medication prescription might not work since they may want you to go through the whole new patient thing. Think about asking a local psychiatrist to do it maybe?

Horrible situation, hope it works out.
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Old Sep 8th 2014, 10:33 pm
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Default Re: Problems getting healthcare referrals

The pediatrician can't prescribe the medication, it has to be a psychiatrist and it is one of those who we're having trouble getting. But thanks - good idea. Theoretically we'd "only" need to see one 4-5 times a year, plus have certain blood tests twice a year which would probably have to be paid for in cash as well. It might still be better than a half day, 140 mile round trip every month though!

(And KP family plan at $1147 per month with relatively high copays on the Platinum plan is pretty "eek")
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Old Sep 8th 2014, 11:04 pm
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Default Re: Problems getting healthcare referrals

If the psychiatrist does the blood tests (ie draws the blood) they probably send it off to a lab, in which case you may not have to pay for the tests out of your own pocket provided the lab accepts your insurance. Maybe you could arrange to go to a local lab to get the blood samples taken anyway if the doc will write the prescription.

Have you thought about registering your son at a normal family doctor's instead of a pediatrician? Would that be possible, would it be any easier?
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Old Sep 8th 2014, 11:46 pm
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Default Re: Problems getting healthcare referrals

Not sure how old your son is, but am assuming he's involved with Regional Center in some capacity.... Can they offer a suggestion?
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Old Sep 9th 2014, 12:05 am
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Default Re: Problems getting healthcare referrals

Hah, Regional Center is another issue! We didn't bother at our previous address because we were getting more than enough help from Kaiser and the school district. Up here it's a whole different world, though last we heard the RC is a self-referral. He's 6, first grade.

Family doctor instead of ped, nope, has to be one of the two listed peds per the plan. Wife did find out there is a new one in the area now, who we might switch to. The original one is fine - just overbooked and overworked, and though he's referred DS to the psych, it's the insurance who actually supply one, and that's where they're failing.
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Old Sep 9th 2014, 1:00 am
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Default Re: Problems getting healthcare referrals

Can you appeal to the health ins co. Or could the employer? They may take more notice of the company?
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Old Sep 9th 2014, 1:47 am
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Default Re: Problems getting healthcare referrals

Originally Posted by MsElui View Post
Can you appeal to the health ins co. Or could the employer? They may take more notice of the company?
Yeah but it's who exactly to appeal to. Bearing in mind she's an RN at the hospital that provides the cover, and - for better or worse - a quite small insurance co - you'd think it would be simple. Well, I say the hospital that provides the cover, but the insurance company and the hospital have the same logo! So I don't really know, all rather confusing. Then we have this Anthem Blue Cross thing as well, which - AIUI (which, I admit, counts for little) - is more for wider in-network coverage than the immediate area.

Actually most of the above is probably rubbish. There are so many fingers in the pie I'm not entirely sure who does what! My insurance card lists four different companies alone. Bah!
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Old Sep 9th 2014, 2:11 am
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Default Re: Problems getting healthcare referrals

From your previous posts, you are on an EPO plan and those are generally very restrictive plans. Open enrollment should be coming up shortly and you should probably switch to a PPO or HMO plan if her employer offers those plans (I've never heard of a business offering only a EPO plan). Until you can switch plans, I don't have any advice.
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Old Sep 9th 2014, 3:02 am
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Default Re: Problems getting healthcare referrals

Originally Posted by Michael View Post
From your previous posts, you are on an EPO plan and those are generally very restrictive plans. Open enrollment should be coming up shortly and you should probably switch to a PPO or HMO plan if her employer offers those plans (I've never heard of a business offering only a EPO plan).
Correct and oh yes!
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Old Sep 9th 2014, 6:34 pm
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Default Re: Problems getting healthcare referrals

Looks like you definitely need to get into a new plan that has more providers in your area. Hopefully your wife's employer provides better options in the next enrollment period. If not, do you have an employer who offers a different health plan? Before you sign up for one (whether through your employer or your wife's), get a list of the plan's local healthcare providers and check that they are accepting new patients.

Has your wife approached her employer to explain the situation? There should be a HR/Benefits dept that has experience dealing with these issues.
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Old Sep 9th 2014, 6:48 pm
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Default Re: Problems getting healthcare referrals

Yes, she's been speaking to her HR department but they are of limited help - helpful but can't really help any more than what she's done already.

I'm self employed and, in CA at least, companies of one don't qualify for small business plans.

Some progress overnight: the new ped in the area has a very helpful secretary who has offered to get the ball rolling even without all the paperwork received yet. And the kids have an appointment this Thursday which is remarkably soon!
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Old Sep 9th 2014, 6:51 pm
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Default Re: Problems getting healthcare referrals

Originally Posted by GeoffM View Post
.... Some progress overnight: the new ped in the area has a very helpful secretary who has offered to get the ball rolling even without all the paperwork received yet. And the kids have an appointment this Thursday which is remarkably soon!
Congratulations on cutting through the bureaucracy, sometimes that is the most difficult step, but is necessary to get you started.
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Old Oct 20th 2014, 7:14 pm
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Default Re: Problems getting healthcare referrals

So I have a relatively rare eye condition that my daughter has unfortunately inherited. I get referred to a retina specialist doctor and all is well, and I ask if he would see my daughter too and he confirms that pediatric retina is within his remit.

The health insurance provider, on the other hand, knows far better and wants DD to go to a hospital that is an hour away for eye checkups with a person of unknown speciality. They refused the referral to the local specialist.

We already have to go do a different doctor for DS theoretically every month but they've at least cut it down to every two months on the basis of it being an hour away from us. (And the other day I got stuck in a freeway closure on the way back, meaning the 3 hour round trip turned into an 8 hour nightmare)

Aaaaarrrggghhh. What we're experiencing with this provider is clearly the type of system that everybody moans about. Double billing for copays. Faceless unskilled dimwits in a dark office building somewhere arbitrarily approving and rejecting referrals. Faulty IT meaning I never get anything by email that they keep promising.

Can't wait for the new year when SWMBO can switch plans.

/rant
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