Challenges with insurance

KFF Health News published an article chronicling the struggles that one family experienced in getting medical care. Unable to find an in-network pediatric ophthalmologist, the family asked their insurer for a "network gap exception, under which the insurer would cover the recommended doctor's services as in-network." The family received a letter indicating that the procedures would be covered. However, after the surgery, the insurer only covered the services as out-of-network rather than at the much cheaper in-network rates.

While the episode was eventually resolved in the family's favor, it should not have required the involvement of a state senator. Wording from the insurer's letter stated that "These services will be covered at the network level because currently there isn't a doctor, health care professional, or facility in your area to provide these services." However, the insurer apparently denied ever sending that letter, telling the family "there was no record of its approval to cover the surgery as in-network." The insurer also claims that while they agreed to cover the procedures, they did not specify that they would cover it as in-network. However, that line of reasoning essentially nullifies their response to a request for a network gap exception: the family should be able to presume that procedures performed out-of-network would have been covered under the out-of-network rates.

To review, the insurance company does not offer what one might consider adequate provider coverage in an area where they sell insurance plans. To compensate for cases like these, the industry has developed a practice, which requires additional effort from the patient. The insurer issues an approval, and then reneges. It seems likely that a lower-level employee mixed something up, but even still, the family should not have to spend enormous amounts of time to correct the insurer's mistake.