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Gosh I wonder if they would do a retro PPO waiver where the insurance would agree to pay at the in network rate? What type of provider is OON? Oncologist, facility? Can he switch to an INN provider that would continue his current treatment plan? If not, he might consider a new plan where his providers are INN for next year.
This is great information. Let me check. Thank you Sheri. I will look into switching to an in-network provider. Jeff, I would appreciate that. Jeff, I will get back to you.
Thumbs up to earlier responses. I'll add a) hospital may be hesitant to go self-pay route once they've started dealing with insurance b) IF you can get insurance worked out and paying, then be really cautious about switching plans which could disrupt care
Hi! Prior auth are certainly an important right and tool available to the insured. However, the insurance company will review the request based on the terms, exclusions, limitations, and medical necessity criteria established in the policy the member agreed to when enrolling.
For that reason, it is very important to obtain the policy certificate and carefully review whether the services, diagnoses, or treatments involved are excluded, restricted, or subject to specific requirements. This helps create a clear roadmap of the viable options versus actions that may ultimately waste time or delay progress.
The negotiation of the existing medical bills will also be very important. In my experience, one-time payment settlements are often one of the most effective strategies when bills have already been issued and all available appeal options have been exhausted with the insurance company or any applicable independent review organizations.
I also agree that looking for in-network providers is a very thoughtful strategy to help ensure access to treatment, which should remain the top priority, while keeping the patient’s cost-sharing as predictable as possible. This can also give the client time to evaluate other insurance options during open enrollment and potentially enroll in a plan that may be accepted by the preferred provider.
Overall, these are all thoughtful strategies, but they should be carefully organized into a structured plan with several options moving forward simultaneously. The goal is to support the patient’s priorities in a practical and realistic way, always with the patient’s knowledge, understanding, and agreement.
Dalia, thank you for these excellent insights. The situation has become significantly more complex, and I may need to enlist your expertise as well. To further complicate matters, I have reason to believe the patient is Canadian, which adds another layer to this case.
They never filled out the paperwork that he lives in the states now as a citizen. So insurance will end 6/30/26 no matter what. Which is a good thing. He can get new insurance through the market place without pre existing?
Can you give me a call tomorrow? Any time. This case had gotten deeper. I'll fill you in. Maybe you could take it over.
Annemarie Schwier
732-865-1804
For that reason, it is very important to obtain the policy certificate and carefully review whether the services, diagnoses, or treatments involved are excluded, restricted, or subject to specific requirements. This helps create a clear roadmap of the viable options versus actions that may ultimately waste time or delay progress.
The negotiation of the existing medical bills will also be very important. In my experience, one-time payment settlements are often one of the most effective strategies when bills have already been issued and all available appeal options have been exhausted with the insurance company or any applicable independent review organizations.
I also agree that looking for in-network providers is a very thoughtful strategy to help ensure access to treatment, which should remain the top priority, while keeping the patient’s cost-sharing as predictable as possible. This can also give the client time to evaluate other insurance options during open enrollment and potentially enroll in a plan that may be accepted by the preferred provider.
Overall, these are all thoughtful strategies, but they should be carefully organized into a structured plan with several options moving forward simultaneously. The goal is to support the patient’s priorities in a practical and realistic way, always with the patient’s knowledge, understanding, and agreement.
You can do this!