a person surrounded by doctors in network and others being blocked out pf network

When You Want to Switch Doctors but Your Insurance Denies It

Let's say you're not satisfied with the way your doctor is managing your diabetes treatment. So, you decide to change your doctor. An acquaintance tells you about a fantastic doctor in your area. You contact your insurance company to switch doctors. Unfortunately, they can't begin the process. Your doctor is the only one qualified to treat diabetes.

You're frustrated. How could this be? Why would the insurance company deny the switch? Your insurance policy holds the answer.

Insurance plans and their impact on your choice of doctors for diabetes

If you're unsure of your type of insurance policy, review it to see if it is a PPO, HMO, or EPO. Finding out this information will help answer exactly why the request has been denied:1

  • Preferred Provider Organization (PPO) plans allow you to see any provider. However, the out-of-network costs for PPOs are higher.
  • Health Maintenance Organization (HMO) plans allow you to seek treatment only from your insurer's local network of providers. There's no coverage outside of the network except in an emergency.
  • Exclusive Provider Organization (EPO) plans allow you to see providers outside the network, but providers will not be covered.

In short, if you have an HMO plan and your friend highly recommended a doctor that's not in the insurer's network, then that's probably why your request to switch doctors was denied.

Am I stuck with this doctor?

No, certainly not. Even though the situation is not ideal, the following options might be worth considering:

Make the long trip to see a new HMO doctor

For example, your doctor is the only qualified doctor in your city that treats diabetes. But, there's another doctor that's 45 minutes to an hour away. This new doctor is also qualified to treat diabetes. So, if the new doctor is better suited to treat your condition, then take the time to travel the extra distance. Plan your day carefully around the appointment and do not plan too many major activities on that day.

Think about switching your health plan to see doctors outside your network

If you are considering switching to a PPO plan, you should keep in mind that it will increase your premiums. Evaluate your budget to determine whether or not it is worth the extra cost.

Consult a diabetes specialist

Check your proof of coverage or your insurer to see if your health care plan covers a diabetes specialist. Your current physician may not be able to adequately answer questions about diabetes that are unique to a certified diabetes specialist. The health plan might require a letter of medical necessity from your current doctor to determine whether the extra care is medically necessary.

We have a right to receive competent and consistent high-quality care. If we're not happy with our current treatment, we may also get a second opinion.

Don't settle for mediocre medical care.

By providing your email address, you are agreeing to our privacy policy.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Type2Diabetes.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Join the conversation

Please read our rules before commenting.

Community Poll

How confident are you that you know all the ways you can spend health savings account (HSA) and flexible spending accounts (FSA) funds?