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Is it typical for PANDAS dr. to not file insurance?

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I am just starting on this path, and found Dr. O in Charlotte NC. But she does not file ins. and is cash at service only. Is that typical? Our adoption assistance will possibly make payments directly to providers, but the medicaid must deny first. If the dr. won't even file, I lose the access to $ that could make services even possible. Am I going to run into this everywhere I go? Any NC dr. recommendations?



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There are many doctors in the Pandas, autism, lyme and integrative medicine fields that don't submit to insurance for payment. Insurance co.s will generally only pay for a 20 min consult and these doctors feel they need additional time with their patients in order to treat properly. But all the doctors we've worked with gave us a red insurance claim sheet. We pay the doctor at the time of visit and then take the red form and file it, along with our insurance co's claim form, to the insurance co directly. The insurance co then processes the claim.


Generally, the ins. co. approves 60% of the charges by classifying the doctor as "out of network". If we've met our deductible, they send us a check for the 60%. If we haven't met our deductible, that 60% gets applied toward our deductible.


Is it a pain to submit your own claims? Yes. And from a cash flow, you're the one laying out the full amt and then waiting to get some portion of it back. But the upside is you get more time with an expert doctor (which can save months or years wasted with the wrong doc). You can always call your insurance co and ask how the process works with them specifically, and with your specific doctor's name. And ask how you'd go about filing your own medicaid claim if you were to use an out-of-network provider. It may be do-able.

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Short answer is Yes.


The Doctor's will try tell you it's "not" about money. But the truth is, It's all about the money. The Group Insurance system is predicated on a fixed billing rate. Doctor's working outside the main stream have to spend more time per patient and can't afford the fixed rates so they opt not to bound by group rates. Since these doctor's care so much about the patients, they will help you file the forums need to get reimbursements. (sarcasm) To be fair they are running a business.


You have to be proactive about getting the information, perscriptions etc. that you need. Don't wait for them (the organization) to do anything.

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4nikki.....I agree the short answer is yes. I really hope I am not reading the post wrong as to who your are sarcastic about......Pandas docs, Insurance co's, or whoever......If I am.....I truly am sorry, but I had to chime in.


(If I am reading your post correctly-----sorry in advance if I am not) I strongly disagree with the sarcasm. It is about money to some extent........but, I would venture to say many of the Pandas docs, for many reasons, including ones you listed, are why they don't take insurance.....including limited treatments and not being able to get reimbursed for services or tests or treatments. Many, if not most give a rip about our kiddos and to a slightly lesser extent, our families. Pandas, Autism, Pans and the whole alphabet soup diagnosis, can be very difficult on a child and family.


Any treatment outside the, what I call, "lame stream' medicine is "oh so bad......not standard protocol" So much is dictated by the govt thru regulation, the CDC, AMA, AAP and then Medicare. We are slowly being corralled into a single payer system with "standard treatments" where we won't have any choice whatsoever on varying treatments or alternative/natural medicines. The un-Holy alliance with Big Govt, Big Pharma, AMA,AAP ect will limit and hurt the ones that need the most intervention.


I tried with regular docs with my Pandas/Pans kiddos to try and get help. We were desperate, as we had behaviors, tics, movements, neurological stuff, psychological stuff.......the whole gamut.


I refused to pay two bills where I got jack**** out of the visits and got no help.......whatsoever.......just a "put her on an SSRI" from some young punk Pedi that did not know "jack****.


But I went to a DAN/Integrative doc before he became a"Leading Pandas Doc" and spent 4 hours on our first visit, got the help we needed and have paid a ton of money for visits, abx, supplements, testing etc.......


You tell me.....few hundred bucks for nothing.......VS.....15k over a few years for attentive doc and staff, treatment, help and valuable info to help manage the situation and future infections and exacerbation's. For us, there was not a price tag I could put on my daughter being happy, healthy....... all that she could be.........let alone..........my family functioning optimally.


I know some on this board are not as fortunate to have the ability/resources to get to a good doc. But I had to comment that I think it is more the insurance companies and their alignment with big govt that are allowing our kiddos to fall through the cracks in our system.

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Doc doesn't accept insurance. He spends a lot of time with us. Works to fight insurance for things like IVIG. He is also helping with disability paperwork for youngest son. Seems like there is always a question about something Lyme or PANS plus endless prescriptions to refill etc...

Our doc has 2 offices and 4 gals on staff full time. His rates are high to me probably the norm now. 4 years of treating 3 in family with Lyme.

Insurance has paid for meds, IV, IVIG, labs and diagnostic things like MRIs. I don't complain too much as it is worse for many.

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worried: My sarcasm is not directed specifically at any doctor or organization. It's frustration about how doctors are backed into a corner forcing them to opt out of the group systems and charge higher rates. The problem for (us) is that we can't benifet from group purchasing power then we have to pay single rates. I hate the hyprocracy through.


[Let's continue: Doctor opens own practice - doesn't take on the group insurance bureaucracy - delayed billing payments + now can bill at 3, 4, 5 enven 6 times higher rates than group insurance rates + collects immediately + Cuts overhead + prioritizes new patients optimizing accounts receivable due to lack of overhead because there's not enough time to make follow ups]


So your point is "You get what you pay for" [?] I started out trying to find doctors within the group insurance, then I discovered, most don't have the expertise, and the one's that do, are overwhelmed. The mature doctors with the experience having thier own practice, seem to have the most expertise and it shows in what they charge for services. [sometimes we get lucky] I find that the better service for your buck is with larger university/research hospitals where they can process insurance and have the resources to find out what's wrong with our kids. Mature doctor's often hang around one or two days a week.

Edited by 4nikki
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