General coverage question


New Member
I am assuming someone out there has faced this issue (I can't be the only one, right?).

My son is currently undergoing an evaluation at the University Autism Clinic in our area. He was referred for the evaluation by his psychiatrist. Both the psychiatrist and the Autism Clinic are out of network (of course!). Our insurance company requires that we have a referral from our primary care provider(PCP) for specialist care. Our PCP provided the referral for the psychiatrist & the psychiatrist provided the referral for the Autism Clinic. I have just learned (after two appointments at the Autism Clinic) that the insurance company will not accept the psychiatrist's referral to the Clinic because the psychiatrist is out of network. This means that we have to have the PCP provide the referral & the two vists we already have hade will not be covered :Hot Head:
Is there any way around this? We thought we were doing everything according to the insurance company's policies, but are now on the hook for about $1,000 in bills and may not even get the referral before the vist schedulaed in two days. If we don't, we will not even file a claim because the evaluation is 4 visits and costs $2,000. If all we have covered is the final visit, it will fall under the deductible and they will not cover anything anyway.

I am trying not to offend, but I am so angry with insurance companies right now & am convinced their primary activity is to find ways to make the process so confusing that no one can possioble navigate their regulations and actually get coverage.

Please let me know if there is anything that might work so that we do not go broke getting the evaluations my son needs to sort out what is going on with him. Thanks!


New Member
I'm not sure how it works in your state with state aide for special needs children..I live in CT. I adopted privately so my son didn't fall under any forster/adoption state aide, however, after much research I found the state offers additional insurance coverage to working families with children, who can not cover all the medical bills. It's done on a sliding scale in accordance to your ability to pay. Maybe your state offers something along these lines you could look into for some relief.


Did you put in an urgent call to the PCP and ask him to fax over the referral to the autism clinic? Some docs will back-date the referral... in this case because the pcp clearly should have written two referrals so it's the PCP's fault!!! that would be my position anyway!

I have had similar situations and worked it out with the insur co- appeal it with the insur co and if that doesn't work with your employer who pays for the plan.


New Member
I will start by saying that it is the employer group who DOES make every decision in terms of what plans they offer and what is in those plans. It sounds as though you have a strict HMO plan where the primary doctor does indeed have to provide the referrals. In those plans it is the member's responsibility to know those rules and to make sure the primary doctor is aware of the need for the second referral. Also in an HMO type referral system, out of network doctors generally are not allowed to refer, primarily because they are already costing the employer group ultimately more than if the in network provider was seen. That is because the insurance company that so many love to hate, has worked out payment agreements that make the cost to the employer much more reasonable than out of network doctors. OON ptoviders charge fee for every service and expect reimbursement at their rates no matter the cost. That is why you have a higher copay or percentage to pay.
As to the post dated referral, not sure that will fly now if the insurance company already has the claims in hand. In other words they are already aware of the visits and in essence the doctor would be committing fraud. The BEST way to handle this as I always say is to call your insurance company and speak with a customer service or member service supervisor and ask for the appeal process. Many times those big old bad insurance companies will accept your explanation and pay it. I again say that insurance companies have to have rules as they are held accountable by the employer groups to try to provide the most cost effective coverage possible. The employers know the rules when they go in. Also if your employer group has high utilization(lots of employees using lots of medical care) they often don't have much of a choice in what they provide, because many insurers deem them high risk and won't underwrite them without strict limits on which providers are seen and how often.
I am sorry that I seem defensive, but I really am getting tired of the insurance companies getting the blame allll the time. The employers know exacting what they are getting for their employees when they accept the contract.