Working with Your Insurance Company

Insurance companies have considerable influence on the referral process. Many family doctors and general pediatricians have referred children with a complex condition to a pediatric specialist, only to discover that the patient's insurance company would not provide coverage. The specialist was not part of the insurance company's physician network, and the insurance company instead recommended a specialist with less experience in treating children or the specific condition of the patient.

You and your primary care doctor should gather information about the specialists included in your insurance company's plan. Evaluate their pediatric training and how much of their practice is devoted to treating children. This will help you make an informed decision about the medical care your child receives.

If you do not believe that a specialist recommended by your insurance company is qualified to treat your child, write the insurance company so that there is written documentation about your concern. Include a list of questions regarding the specialist's credentials. Your pediatrician or family doctor also should write to the insurance company on your behalf. If a strong enough case is presented, the insurance company may agree to provide coverage for a specialist recommended by your child's doctor.

Why do insurance companies sometimes refer children to adult specialists?

• There are many more adult specialists than pediatric specialists.
• Insurance companies have more contracts with adult specialists than pediatric specialists.
• Many insurance companies believe that it costs less for a child to see a specialist with whom they have a contract.
• Insurance company employees may not understand the difference in training and experience between an adult and pediatric specialist.
• Insurance company employees may not understand that illnesses affect children very differently from adults (e.g. arthritis and diabetes), and therefore require specialized treatment.

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