A mother takes her 4 month old son to the Pediatrician’s office for a well baby check-up and a series of immunizations. The mother works, but is naturally taking the time to take her son to the doctor’s appointment. She arrives, and signs in at the appointed time. The Pediatrician’s front office person calls her to the front desk. The mother is informed that the Pediatrician is no longer a Member of her Health Insurance Plan’s PPO Network. As a result, she will need to pay $999.00 for this visit which includes exam, and vaccinations. If the mother went to a Pediatrician in the current Health Insurance Plan’s PPO Network , the health insurance coverage for immunizations is 100%; and no money is needed on date of service. But, she was not aware of the recent change in status of the Pediatrician’s participation in the Health Insurance Carrier’s PPO Network.

You see, the Health Insurance Carrier delivered its new FEE Schedule to the Pediatrician six months ago. The new Fee Schedule informs the Pediatrician what it will reimburse for the medical services provided to the Health Plan’s subscribers…and that Pediatrician declined to participate in the Health Insurance Plan’s PPO Network. Reimbursement from the Health Insurance Carrier was below the cost of immunizations, lending to the Pediatrician’s decision to terminate its participation in the PPO Network. The Mother has used this Pediatrician for years. The Pediatrician tells her that if she cannot pay $999.00, then they should reschedule the visit when she has new Health Insurance.