Sleep Doc I Sought Now Out of Network- How to Get a Referral

I've met with many sleep docs over the years and have learned how to pick up on some things over time. I had done extensive research to arrive at a certain doctor. I didn't have insurance last year and called Anthem on December 22 to see if a particular sleep doc was in-network and they assured me that she was and it was the sole reason I chose the Anthem plan.

I made an appointment after the first of the year and just beforehand I recieved a call that she is longer in network. Its a plan through the Colorado Exchange and is Anthem Pathways Essentials, which not even my PCP takes now. I hadn't thought to check on my PCP as they seem to take everything and I can pay cash for a few visits a year with him, as I have in the past.

I learned of this particular sleep doc being out of network after January 15, which was the last day I could make a change of insurance plans. Apparently this is the real time to check to see who is in network for a new year - those 15 days after the first of a year and not the end of the prior year. Thought I had done my homework, but now looks like the 15 days after January 1 is more important. I cerntainly felt taken-advantage of, but have to operate in the current plan-year.

Anthem related that if I have an in-network doctor send me to the particular doctor - a referral that may not be the right term for the situation - that I would be covered in network with the doc who is now out-of-network. Of course an in-network doctor may be discouraged from doing this. I made an appt with a PCP who is in network and my general approach would seem to be communicating on that first appointment that I'll come over to this clinic on an ongoing basis if I can obtain a referral. Don't know what else to do but to appeal to their economics, which seems to drive many days.

Of course, this is quite old-fashioned. Any suggestions on how to get referred to a doctor that was in network just before the end of the year, but now isn't in the new plan year. I had even spoke to patients of hers and have smootched some frogs along the way, otherwise.

Yes, I have a new CPAP machine coming- which should bring me into the 21st century! I would have changed my signature but it hasn't arrived yet.

I promised not to tell!

Why do you need a sleep doctor on an ongoing basis? I haven't seen one in 12 years.

Papman454 wrote: ↑

Thu Feb 11, 2021 11:14 pm

made an appt with a PCP who is in network

Same question as LSAT: Why do you need a sleep doctor?

My PCP renews my CPAP prescription at my annual checkup. He also sends a letter of medical necessity to my local DME. This is a PCP who, by his own admission, knows almost nothing about CPAP. He promised to write whatever I need.

Do you use OSCAR? Except in very unusual cases, it beats the pants off sleep professionals.

I will offer a third vote for WHY DO YOU NEED A SLEEP DOCTOR.
I have had 2 sleep studies in 10 years.
I have seen half a dozen sleep doctors. Only one was as good as this group and he turned out to be out of network and refused to see me again.
I met another capable sleep doctor through my brother in law.

Learn to use OSCAR and get help from the experts here.

I certainly would not return to any PCP who refused to give me referral to see a doc I want to see - even if it's just for coffee.

While, as suggested, any doc can *legally* certify you have met requirements for your insurance it is frustrating that a doc or medication you have used successfully in the past is no longer allowed by Anthem, Aetna, or any insurance. Exactly, why I dropped Aetna and returned to good 'ol Medicare. While Medicare doesn't cover some other things I would like - My co-pay covers anything that Medicare covers. You have to choose your poison.

Does the doc you want to see take Medicare?

If so, there are some *life events* which may qualify you to change before the next enrollment period. You will have to research to see if you qualify for any *Special Enrollment Periods* but moving is one - turning 65 is another.

And you may even qualify just before the next *Annual Enrollment* - as in 1 or 2 months before. Which gives you time to try one for a short period.

Most docs will take Medicare and may not require a referral. See if this is an option for you.

For me I prefer a sleep doc whois a pulmonologist and at some point you may need that specialty and feel much more comfortable having already selected that specialist doc.

My PCP will not do anything my specialists cover.
You'd think he should give a discount.