being denied healthcare

October 3, 2022 12:41 PM

Is this legal?

Hi, I'm here again and hopefully this does not constitute abuse of the unlimited questions allowed on AskMe now. If so, mods, please remove and accept my sincere apologies.

I have PCOS. It presents with insulin resistance. I literally just got home from the doctor after having a cyst burst and now I have to deal with another kind of medical shit show on top of personal problems at home. I have been trying for six months to get an appointment with an endocrinologist local to me as I have recently moved. The insurance related bureaucracy has been a nightmare. I finally found a practice nearby accepting new patients and my PCP faxed over a referral as well as recent lab work. The lab work indicates that my current A1C is 6.6. I am 37 years old, have been in treatment for PCOS since I was 15, and my A1C has never been this high. Technically, I am now diabetic. I am terrified. Diabetes runs on both sides of my family and my grandmother died of diabetes -related complications. I take Metformin but I am running out of meds, my PCP is willing to prescribe it to me but would rather I be under the care of an endocrinologist, she doesn't want her prescribing me these meds to be an ongoing thing. Fair.

The local endocrinologist practice received my PCP's referral and the lab work and sent over a message to my PCP this morning REJECTING THE REFERRAL, specifically citing my A1C as the reason for the rejection. I am diabetic, and they don't think I need to see an endocrinologist?!

I called them demanding an explanation and they asked if I could contact my former endocrinologist for my medical records I guess to "prove" that I've been under the care of an endocrinologist before. What the actual fuck. I called my former endo and spoke with her nurse, and she literally also said "What the actual fuck." They are faxing over all of my charts posthaste (including records they obtained from two prior endocrinologists I was under the care of when I was younger). The nurse was infuriated in my behalf and said I really should look for a different doctor and also legally this practice cannot deny me medical care.

Is that true? Like, legally is that true? Because if it is, I'm prepared to call that practice back and raise bloody hell with them. I am literally recovering from a burst ovarian cyst as we speak. My A1C says I am literally diabetic. I am livid. If they are indeed doing something illegal right now I want to get confirmation from them and report them, but I want to make sure I'm not, like, jumping the gun or working with incomplete information as I am not a doctor or a lawyer.

Thanks.

posted by nayantara to Health & Fitness (10 answers total)

Medical administration can be horrible to deal with. Since you have so much going on RIGHT THIS MINUTE - physically, emotionally, romantically - I would try to put the illegality question to the side for the moment. Work on getting the care you need and deserve. There will be time for legal questions later.
posted by nkknkk at 12:50 PM on October 3, 2022 [3 favorites]

This sounds so frustrating. To answer your question, typically yes, a physician can decline to see a new patient. They do not have to accept every referral they get if they do not feel the patient is appropriate for their clinic for whatever reason. Things get a little more complicated if a physician decides they can no longer treat a current patient, but there are guidelines for physicians to end treatment in an ethical and safe way (not that these are always followed).

I would try to see if you can get a referral to another endocrinologist. You may also want to talk directly to your PCP to get her thoughts on what’s going on. Sounds like there is a lot of information traveling around you, but not directly to you.
posted by namemeansgazelle at 12:56 PM on October 3, 2022 [11 favorites]

Best answer: I don't know the answer to the legality question, which seems like a thicket that you will likely spend a lot of energy on without being satisfied. Your insurer might be able to help both with the technical legality, but also to find you an endocrinologist who will see you. Specialists often limit their patients to those that fit within their specialty, and not every endo specializes in diabetes, though it is a huge proportion of most practices. They do have the right to decide who to accept.

But . . . if you do decide to call and raise outraged hell and are aggressive with the staff and/or use profanity, they will not accept you in the practice. I worked in several medical practices and rude patients, or patients who insulted or cursed to the staff were immediately dismissed from the practice. Sometimes we called security to escort the person out. That is definitely legal.

Also agree with akknkk above. Your first priority should be getting care. If your previous endo sends all the records and you follow up with the new office (politely) you should be able to get on the schedule. Asking your previous endo to message the new office to introduce you will go far. Doc to doc referrals are prioritized, especially if your previous doc makes direct contact.
posted by citygirl at 1:12 PM on October 3, 2022 [13 favorites]

If you are in the US, no, there is no legal obligation for a doctor to take on a new patient. Once you are an accepted patient then there is a duty of care, but until then, they do not have any obligations to you. Fort example, this endocrinologist could decide they want to specialize in treating a specific type of disorder and only accept patients with that disorder. In this case they may have decided they want to focus on making their limited new patient spots available to people with severe uncontrolled diabetes, for instance. I'm so sorry that you're situation is so awful and I hope you get the care your need.
posted by Ausamor at 1:23 PM on October 3, 2022

Is this a provider that is in-network with your insurance? In-network specialists are generally not contractually allowed to turn new patients away as condition of their contract. You might take it up with them to see if they are in violation of their contract.
posted by ThePinkSuperhero at 1:33 PM on October 3, 2022 [1 favorite]

Best answer: It is very very unlikely that you will get any recourse or the satisfaction that you want, but even if you did this is a later problem, not a now problem. It would take at least 18 months to get any results from a regulatory or insurance complaint. You will get more immediate satisfaction, and very likely more consequences, from a bad Yelp review.

More importantly and urgently: this practice sucks and you shouldn't go there. Finding a competent endocrinology practice is your now(ish) problem. Our healthcare system is mid-collapse at the moment, you may well have trouble getting in any doors in less than 3-6 months.

To that end, you need to work with your PCP until you can actually get in front of an endo.
posted by Lyn Never at 1:46 PM on October 3, 2022 [5 favorites]

Legally speaking, as others have stated, as long as you do not have an existing care relationship, a medical provider does not have to accept a referral.

I am aware of some endocrinology practices where I live that focus on thyroid/pituitary/adrenal issues. The diabetes rates where I live are so prevalent (and endocrinology practices generally so busy), that these patients aren't referred to endocrinology unless their primary care physician isn't able to manage it. Indeed - when I have patients who have endocrine-related side effects from chemotherapy that I manage, I have to make direct contact with an endocrinologist colleague to get them in the door. Wait times for the endos that I use often have a wait time of several months for non-emergent consults.

I'm not saying that they are right or wrong to do so. I will say that a lot of consulting physicians (myself included ) have been seeing insane numbers of patients. There are shortages in a lot of fields, a lot of older physicians retired during the pandemic, and for better or worse, a lot of NPs/PAs do not seem to be as comfortable managing some things. PCPs are also busier and more metrics-driven (e.g. their contracted pay hinges on BP and diabetes control and they are a lot less likely to have the time and energy to focus on managing other issues, so they get referred to specialists).

As a hematologist/oncologist, I am seeing insane volumes of consults for benign hematology issues that would probably have been managed by a primary care physician a decade ago (some hyper coagulable management, a lot of iron deficiency anemia that doesn't require anything other than oral iron). We don't typically turn away any consults unless someone is rude or abusive to the staff. We don't generally turn away consults (for lots of reasons), but it has resulted in a lot of strain on those of us still in practice.

One thing you might consider: working with a direct care endocrinologist if one is available to you. These are physicians who charge cash prices, but will often have contracts with labs and imaging centers that allow for less expensive testing. Patients can actually save money not using their insurance. I frequently refer to one in Texas and because of her business model, she is able to spend a lot of time with her patients and really focus on their goals.
posted by honeybee413 at 7:57 PM on October 3, 2022 [5 favorites]

Best answer: I have been in this situation or a version thereof. I told myself that I needed to focus on immediate care needs first, but also promised myself that when that was accomplished I would write a scathing letter TO the practice and write scathing reviews OF the practice on all publicly viewable forums. And I did. And it was glorious. Get care first. Scorch the earth later. Both are important but order of operations matters.
posted by jeszac at 7:28 AM on October 4, 2022

I work front office for a community health center. For better or for worse: I can confirm that if you write a scathing letter, it will be emotionally impactful for the staff.

Whether or not you want to emotionally impact staff who likely have zero ability to create available appointments at their practice is a decision I won't weight in on. I will echo the other answers that are saying focus on getting your care elsewhere in the short term, as you (and everyone else) deserves medical care.
posted by Jarcat at 7:38 PM on October 4, 2022 [1 favorite]

In the US, almost nobody is obligated to provide non-emergency medical services. Specialists can and do decline referral requests if the patient’s needs do not really fit their practice or they do not have room on their calendar.

I am not saying this to defend their refusal to schedule you, but to suggest the communication breakdown that may explain it. You have (by A1c) pretty well controlled diabetes complicating pcos and are on the first line (and likely most effective) drug. Managing this is well within the scope of practice of a family medicine or internal medicine physician. I think most gynecologists would also be comfortable managing this. Your specific PCP might not be. The PCP vs specialist division is very different depending on where you are in the country and how busy specialists tend to be there. Other facts from your records might show something that needs a specialist. If you were not satisfied/getting good results from metformin and wanted to try a newer drug that could also be a motivation.
posted by a robot made out of meat at 6:39 AM on October 5, 2022 [1 favorite]