Question:
Can I get a referral from my PCP to a surgeon who is not in the network?

My insurance provider covers the WLS procedure and said that I should find a surgeon in the network. However, the only surgeon in the network just did his first RNY in March 2002 and after further research, I discovered that he has several malpractice suits pending for different procedures. (This does not instill confidence.)Is there any way I can have my PCP make a referral to a surgeon who is not in the network? Thanks!    — Destonia (posted on July 1, 2002)

July 1, 2002
This is a question best answered by your insurance company. My insurance company would allow the referral but would cover a lower percentage of the bill (70% instead of 80%). Many times a surgeon who is not in the network is associated with hospitals/labs/etc. that are also not in the network. This presents the potential for a lot of extra money out of the patients pocket when you look at the long term picture. Is your insurance company aware that the only doctor they have in their network for this procedure has pending malpractice suits against him? I would call and speak to a representative at the insurance company about this. There should be an alternative for you. Good Luck.
   — Pam S.