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.
BIGBLUE
