Back Pain, Sore Neck, Chiropractor

Dimond Chiropractic of Armstrong County, PA

Second Opinion: Provider quit the plan, so coverage ended

If you have questions about the practices of your managed-care coverage, ask the experts at the state Department of Managed Health Care. I received physical therapy for two years as post-surgical treatment for a fractured ankle, and my health plan paid part of the cost. But this year, my plan stopped making payments because the individual from whom I received these services was no longer considered a "preferred provider" or a certified physical therapist. When these claims were initially denied, I was told the reason was that "services provided by naturopathic doctors are only covered by the patient's plan when rendered as emergency services and care." I found that interesting, given that the plan had provided partial payment for past claims from the same provider with the exact same codes for procedure and diagnosis.

– Dawn Perry, Sacramento

Your complaint highlights an aspect of preferred provider organizations that is often confusing. While PPOs provide enrollees with more flexibility in choosing providers than do HMOs, enrollees need to know the terms of their benefits to avoid unexpected expenses.

The DMHC's review showed that for the first two years, the claims were submitted to your health plan by one of your plan's preferred physical therapist companies. Preferred providers contract directly with a health plan to provide services to members, usually at a discount. Because your provider was recognized as a preferred provider, your health plan paid the claims. However, in June 2008, the provider asked your health plan to be removed from its preferred provider list, and changed the company name to reflect that it no longer employed physical therapists.

Although you continued to receive the same treatment from the same provider, the business relationship between your provider and your health plan had been severed. According to the terms of your coverage, physical therapy is defined as treatment provided by a doctor of medicine, or under the direction of a doctor of medicine when it is provided by a registered physical therapist, certified occupational therapist or licensed doctor of podiatric medicine. Because your provider is not a registered physical therapist, he does not meet these criteria. As a result, the services you received were no longer a benefit of your health coverage, and it appears that the health plan's denial of your claims was appropriate.

Providers should tell their patients when they are no longer preferred providers. However, to avoid problems, patients should ask their providers before services are rendered whether they remain contracted with the patients' health plan and therefore continue to be a preferred provider. It is also a good idea to periodically check the health plan's Web site or call member services to confirm that the services will be covered at the preferred provider rate.

If you have questions or concerns regarding your health care coverage, call the DMHC's Help Center at (888) 466-2119, or go to www.healthhelp.ca.gov.

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