MA Out of Network Issue

Apr 15, 2019

  1. vic120
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    vic120 Guru

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    I have a client on MA HMO.

    Here is the issue she got referred to Physical Therapy And told them which plan she had and what copay was, She went from Jan till Now

    Now she started getting bills in the last few weeks, She called and they said They are out of Network and that she would have to pay all this money owed.

    She told them she told from the beginning and what copay was and also that they have been taking copay all this time that she should not be responsible because they made it as they took it

    They said it's not their problem and that should wound need to pay all monies owed

    As far as the primary she asked why was she referred out of network Doc said she does not know who is in the network and is not responsible for referring in network

    Does she have any recourse in this case?
     
    vic120, Apr 15, 2019
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  2. JProducer
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    JProducer New Member

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    If the provider who referred your client is a participating provider, the health plan is obligated to pay for the out of network services. It’s called “plan directed care”. Tell your client to file an appeal with the health plan. If the appeal is denied, your client should file a grievance with CMS.
     
  3. vic120
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    vic120 Guru

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    Interesting

    Although I am still kind of shocked that the provider for PT is not responsible because she was upfront about what cov she was using and that she has been going for 3 months paying a copay each time

    But I will go with primary if no better solution is provided
     
    vic120, Apr 15, 2019
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  4. TwoCents
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    Learned something new. I'd go this route. Here's where the CMS info can be found. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c04.pdf This should open Chapter 4 "Benefits and Beneficiary Protections" then do a word find for "plan directed care" and keep reading until you get to the part about referral to an out of network provider for covered care.
     
    TwoCents, Apr 15, 2019
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