Cigna HMO plan- Dr says she will not take HMOs anymore

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OneWorld111
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Cigna HMO plan- Dr says she will not take HMOs anymore

Post by OneWorld111 » Thu May 15, 2014 8:54 pm

Hello:

We r in a bind as the doctor says she will not accept HMO plans anymore. When I contacted Cigna, they said she is on the contract and should take you as patient.

Cigna says we can file complaint on your behalf but what will I get out of it.

What can we do? We cannot change insurance in the middle as enrollment is not here till Sep.

Thanks,
energy2055

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cheese_breath
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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by cheese_breath » Thu May 15, 2014 8:56 pm

Afraid you're going to have to find another doctor. Happened to us twice when we had HMOs.
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TX_TURTLE
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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by TX_TURTLE » Thu May 15, 2014 9:09 pm

Assuming the information Cigna customer service gave you is accurate, I can think of two possibilities:
1) Your doctor is dropping out of the Cigna network
2) She is not willing to comply with the contract she signed

Either way, it sounds like you need to find a new a new doctor, within Cigna's network, ASAP. I wouldn't sweat it, finding a good primary care doctor is not that difficult, and you may like the new one better.

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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by Calm Man » Thu May 15, 2014 9:25 pm

You certainly are stuck and I agree with you that it is not worth filing a complaint. Going forward this will get worse. So I suggest using this as a learning experience and unless you are financially in serious trouble, I would not enroll in an HMO but would enroll in an open system with as wide a network as possible. I am extremely disappointed in your primary care doctor if she had a long term relationship with you, is still under contract with Cigna and won't see you anymore under the insurance provisions. I can see her not taking new patients but abandoning you is unfair and reflective of a distinct flaw that she has. You are better off without her - shame on her.

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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by TheGreyingDuke » Thu May 15, 2014 9:33 pm

TX_TURTLE wrote:Either way, it sounds like you need to find a new a new doctor, within Cigna's network, ASAP. I wouldn't sweat it, finding a good primary care doctor is not that difficult, and you may like the new one better.
Hmmm, "good" and "not that difficult" :?:

Many areas of the country, rural and or lower income, have serious shortages of primary care. Hospitals spend lots of time recruiting primary care docs, often using highly paid headhunters.
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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by DTSC » Thu May 15, 2014 9:33 pm

If you don't have too many medical problems and don't need much testing, you might be able to negotiate a cash price to see your doctor for an office visit or two.

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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by gnosis » Thu May 15, 2014 9:40 pm

Calm Man wrote:You certainly are stuck and I agree with you that it is not worth filing a complaint. Going forward this will get worse. So I suggest using this as a learning experience and unless you are financially in serious trouble, I would not enroll in an HMO but would enroll in an open system with as wide a network as possible. I am extremely disappointed in your primary care doctor if she had a long term relationship with you, is still under contract with Cigna and won't see you anymore under the insurance provisions. I can see her not taking new patients but abandoning you is unfair and reflective of a distinct flaw that she has. You are better off without her - shame on her.
You might not be as stuck as you think. Call your doctors office, tell them you're getting out of your HMO plan next enrollment period just so you can continue to be with your favorite doctor in the whole wide world, and then ask about self-pay options.

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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by ryk1861 » Thu May 15, 2014 10:47 pm

A couple points:

1. Just because a doc has an agreement with an insurance company does not obligate the doc to accept the insured as a patient. Same goes with Medicaid and Medicare.

2. It is possible that Cigna has cut the rate of reimbursement or changed the rules or has been delaying payment to the doc (a strategy I have seen done quite a bit) such that it is too much of a hassle or burden for the doc to accept Cigna patients.

3. This is going to get worse going forward.

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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by celia » Fri May 16, 2014 2:21 am

Any doctor can have too large a patient load and thus be not willing to see new patients. You can't change that and neither can the insurance company. But possibly the doctor can suggest another doctor in the group who is taking on new patients. At least your records are already there and if it is a patient-load issue, you should be able to go back to the preferred doctor in the future.
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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by Professor Emeritus » Fri May 16, 2014 4:34 am

ryk1861 wrote:A couple points:

1. Just because a doc has an agreement with an insurance company does not obligate the doc to accept the insured as a patient. Same goes with Medicaid and Medicare.
Source for this? I have no problem if there are "medical grounds" ( outside of qualification). (Question is limited to HMO contract, not simple fed or ins co reimbursement)

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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by ryk1861 » Fri May 16, 2014 5:23 am

Professor Emeritus wrote:
ryk1861 wrote:A couple points:

1. Just because a doc has an agreement with an insurance company does not obligate the doc to accept the insured as a patient. Same goes with Medicaid and Medicare.
Source for this? I have no problem if there are "medical grounds" ( outside of qualification). (Question is limited to HMO contract, not simple fed or ins co reimbursement)
Let me flip it as it is impossible for me to prove what I do not have to do. Show me where a doc in an HMO Is bound to see a specific patient. I have signed countless insurance contracts of all flavors and never signed one that bound me to see any specific patient.

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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by Calm Man » Fri May 16, 2014 10:53 am

ryk1861 wrote:
Professor Emeritus wrote:
ryk1861 wrote:A couple points:

1. Just because a doc has an agreement with an insurance company does not obligate the doc to accept the insured as a patient. Same goes with Medicaid and Medicare.
Source for this? I have no problem if there are "medical grounds" ( outside of qualification). (Question is limited to HMO contract, not simple fed or ins co reimbursement)
Let me flip it as it is impossible for me to prove what I do not have to do. Show me where a doc in an HMO Is bound to see a specific patient. I have signed countless insurance contracts of all flavors and never signed one that bound me to see any specific patient.
Of course you are correct ryk. Nobody (at least yet) can compel a doctor or any service provider to provide services to anybody. The Professor sometimes gets carried away but he is well meaning and sometimes goes further than others do in advancing an argument.

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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by OneWorld111 » Fri May 16, 2014 5:35 pm

The issue is it is not PCP, it is a specialist for OBGYN. Thanks for the comments.

We had looked into insurance and then taken HMO.

We have already found a new doctor now.

Taken,
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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by LadyGeek » Fri May 16, 2014 8:27 pm

This thread is now in the Personal Finance (Not Investing) forum (insurance).
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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by madbrain » Fri May 16, 2014 9:44 pm

ryk1861 wrote: Let me flip it as it is impossible for me to prove what I do not have to do. Show me where a doc in an HMO Is bound to see a specific patient. I have signed countless insurance contracts of all flavors and never signed one that bound me to see any specific patient.
I don't know about those contracts as I am not a doc, but there are certainly plenty of federal and state anti discrimination laws that would prevent you from refusing service to certain patients on an individual basis, depending on the reason (gender, racial discrimination, sexual orientation, etc). Obviously that's not the case here since the OP was a former patient.

And also, the OP's situation is a matters of insurance contract, not discrimination law. The doctor isn't refusing to take the patient, but to accept the patient's insurance as payment.

I don't think we know the entire story here.

The OP checked that the provider was in the network at enrollment time.
Now it turns that out that is not the case.
It seems the OP is not at fault. Either the insurance company or the doctor is at fault.

1) Maybe the insurance company has bad records or fraudulently misrepresented the plan's network before selling coverage.
Either way, since the insurance company claimed before selling the plan, and still claims that the doctor should accept the coverage, there should be some sort of recourse for the OP against the insurance company. I would complain not just with the insurance company, but also bring it up with the state insurance commissioner and perhaps state legislator.

2) Maybe the doctor had a contract with the insurance that expired in the middle of this year, and which was not renewed.
If that's the case the OP may be S.O.L. . Insurance companies are allowed to make some mid-year changes to benefits (for example, some prescriptions may no longer be covered/or added), and probably to their their network as well in some circumstances.

But if that's the case, I think there should be some consumer protection against that sort of mid-year change where your provider is dropped.
I think the insurance company should not be able to advertise that providers are in the network at enrollment time, if they don't have a contract that runs through the end of the next year. And in case of mid-year contract termination between the provider and insurance company, for whatever reason, there should probably be some sort of compensation to the consumer who is caught in the middle.

3) Maybe the doctor is in breach of contract with the insurance company. But since the OP is not a party to that contract, it's impossible to tell.

I have no idea about these areas of the law since I'm neither a doctor or attorney. But since you are a doc, maybe you can comment.

I did have a provider dropped once. I was told one day he no longer worked for Kaiser. I think he was fired - I have no idea why. Lips were shut.
I hadn't seen him for long, and I did not complain. I don't know if he tried to open a private practice afterwards or not. There was literally no forwarding address.

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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by grabiner » Fri May 16, 2014 11:16 pm

madbrain wrote:But if that's the case, I think there should be some consumer protection against that sort of mid-year change where your provider is dropped.
I think the insurance company should not be able to advertise that providers are in the network at enrollment time, if they don't have a contract that runs through the end of the next year. And in case of mid-year contract termination between the provider and insurance company, for whatever reason, there should probably be some sort of compensation to the consumer who is caught in the middle.
Check the terms of your insurance plan. My plan, for example, allows you to continue seeing a specialist at in-network coverage rates for 90 days after the specialist leaves the network, and to continue seeing an OB-GYN for the duration of your pregnancy.

This won't help if the specialist drops you as a patient, and will only partially help if she refuses to accept the allowed in-network amount. (That is, if you pay a $10 co-pay for in-network doctor visits, but the doctor charges $150 and the plan approves $100, you will owe $60 if you see her.)
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Re: Cigna HMO plan- Dr says she will not take HMOs anymore

Post by dm200 » Sat May 17, 2014 10:34 pm

Having a physician or medical provider drop out of a particular insurance plan (the one that you have) is not unique to being in an HMO. It can happen with any type of plan (such as a PPO).

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