Want to See a Specialist Doctor Who Does Not Take Your Insurance? There Are Options...

It is not unusual nowadays that a patient may want to see a specific medical specialist who unfortunately does NOT participate with their health insurance plan. This doctor is what is known in insurance parlance as a "non-par provider."

In this situation, there are two options.

1) The patient pays the medical bill (self-pay) and forwards the receipt to the insurance company who hopefully will reimburse the patient.

2) The patient can request a "Letter of Medical Necessity" from the primary care doctor to submit to the health insurance company requesting temporary non-participating provider (non-par) insurance coverage.

What does such a letter of medical necessity entail?

The best way to illustrate this course of action is to provide an example. In my practice, I offer several services that many other ENT specialists do not. As such, there are a large number of patients who travel from even as far away as Florida and Arizona to be seen in our Virginia office. Needless to say, many patients have health insurance plans that I do not participate with.

One such procedure is tonsil cryptolysis.

A sample "Letter of Medical Necessity" that a patient can request from their primary care doctor to submit to their insurance company is as follows (the same concept can apply to any type of procedure or specialist evaluation):

John Smith, MDCountry Lakes Family Practice

Dear [Insurance Company]:

I am writing this letter on behalf of my patient, Mary Smith (DOB: 01/01/1965), who has a 10 year history of cryptic tonsils with production of tonsiliths (tonsil stones) on a daily basis. 

Though this problem occurred intermittently during adolescence, it has recurred during adulthood and has become a chronic problem which has affected her overall quality of life.  These stones consist of debris collected in the crypts of the tonsils together with sulfur-producing bacteria which account for the acrid odor and taste.  

I believe Mary is a candidate for a minimally-invasive procedure called tonsil cryptolysis (coblation therapy).  This procedure uses a radio-frequency energy in combination with a conductive medium to form a low temperature (40-80° C) localized plasma field which allows the precise removal of affected tissue while maintaining the integrity of surrounding, healthy tissue.  This results in decreased pain and a significantly shorter recovery time as compared with more traditional methods of treatment.  This procedure can be done in the office under local anesthesia on eligible adult patients.

After an initial evaluation for candidacy, tonsil cryptolysis can be done in an office setting under local anesthesia.  Most patients (70%) require one session for complete amelioration of symptoms. 

As there are no area specialists offering tonsil cryptolysis, I recommend that Mary be evaluated and treated by a non-par provider, Dr. Christopher Chang of Fauquier ENT Consultants located in Warrenton, VA. Please provide temporary insurance coverage in order for Mary to be seen by Dr. Chang.

Sincerely,
xxxxxxx
Dr. John Smith

That's it!

If insurance declines coverage, than you are stuck with option #1 to self-pay if you really want to see a specific non-participating provider.

In any case, some unique services our office provides for which patients have requested non-par provider coverage include:

• Video/Audio Nasopharyngoscopy for Velopharyngeal Insufficiency
• Endoscopic Staple Diverticulostomy for Zenker's Diverticulum
• Botox Injections for Spasmodic Dysphonia
• Chronic Cough Evaluation
• Phlegmy Throat
• Chronic Throat Clearing
• Allergy Drops