Guest guest Posted May 27, 2011 Report Share Posted May 27, 2011 I'm not much help except to offer support. I'd suggest working from your chosen surgeon's office. They know how to get the HMO's to refer to them. Threats, such as " your decision is causing my husband and our family long and irrepairable mental and physical harm " may escalate your case to their legal department, and I've heard you can get action faster that way. I have a friend that used to work for Pacificare and she said as soon as lawsuit wording came from their members they rolled it over to their legal department and they worded toward a resolution. There have been others here that can help more. Sandy > > Hi everyone, > > I'm ready to scream and so is my husband. After months of waiting, the HMO to which we belong - Brown & Toland - in SF, finally got back to us on our request to have an out of network specialist do the myotomy surgery husband needs. They have refused to let us go out of network even though they have no in network specialist for the surgery. They referred us to 2 in-network MDs who they claim are " qualified " to do the surgery, but 2 of the MDs on the list aren't even surgeons. The other is a general surgeon, and the other a cancer surgeon. > > This is all the more crazy making because our insurance company - Blue Cross -- will cover the surgery if Dr. Patti does it, as they would consider him " in network. " > > I'm so angry and frustrated and scared. We are right back at square one with all this. Meanwhile, my husband is getting worse, losing more weight, looking more haggard, feeling more and more depleted. > > I had no idea before this how much power an HMO has in the process. For once, the insurance company is doing the right thing, but the doctors are hanging up my husband's ability to get the right care.The HMO has been horrible to deal with. everything has to go through the primary care physician's office. No email, no names, no phone numbers of anyone we can contact directly at Brown & Toland. Lots of smoke and mirrors, and we have no idea what to do next, There's some sort of appellate process but I'm not hopeful. > > Has anyone been in a similar predicament? Advice? > > Anyone know how much the surgery costs in the event that we decide to suck it up and pay for a specialist ourselves? > > Sorry for the rant. Just feeling so hopeless right now. > > Thanks, > in SF > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 27, 2011 Report Share Posted May 27, 2011 Do you have Blue Cross or a HMO? Or is Blue Cross and HMO? From: Sandy <sandycarroll@...> Subject: Re: HMO Hell - advice? achalasia Date: Friday, May 27, 2011, 10:18 AM Â I'm not much help except to offer support. I'd suggest working from your chosen surgeon's office. They know how to get the HMO's to refer to them. Threats, such as " your decision is causing my husband and our family long and irrepairable mental and physical harm " may escalate your case to their legal department, and I've heard you can get action faster that way. I have a friend that used to work for Pacificare and she said as soon as lawsuit wording came from their members they rolled it over to their legal department and they worded toward a resolution. There have been others here that can help more. Sandy > > Hi everyone, > > I'm ready to scream and so is my husband. After months of waiting, the HMO to which we belong - Brown & Toland - in SF, finally got back to us on our request to have an out of network specialist do the myotomy surgery husband needs. They have refused to let us go out of network even though they have no in network specialist for the surgery. They referred us to 2 in-network MDs who they claim are " qualified " to do the surgery, but 2 of the MDs on the list aren't even surgeons. The other is a general surgeon, and the other a cancer surgeon. > > This is all the more crazy making because our insurance company - Blue Cross -- will cover the surgery if Dr. Patti does it, as they would consider him " in network. " > > I'm so angry and frustrated and scared. We are right back at square one with all this. Meanwhile, my husband is getting worse, losing more weight, looking more haggard, feeling more and more depleted. > > I had no idea before this how much power an HMO has in the process. For once, the insurance company is doing the right thing, but the doctors are hanging up my husband's ability to get the right care.The HMO has been horrible to deal with. everything has to go through the primary care physician's office. No email, no names, no phone numbers of anyone we can contact directly at Brown & Toland. Lots of smoke and mirrors, and we have no idea what to do next, There's some sort of appellate process but I'm not hopeful. > > Has anyone been in a similar predicament? Advice? > > Anyone know how much the surgery costs in the event that we decide to suck it up and pay for a specialist ourselves? > > Sorry for the rant. Just feeling so hopeless right now. > > Thanks, > in SF > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 27, 2011 Report Share Posted May 27, 2011 Thanks for your support and advice Sandy. We have Blue Cross coverage and the physicians' network is an HMO, Brown & Toland. > > > > > > Hi everyone, > > > > > > I'm ready to scream and so is my husband. After months of waiting, the HMO to which we belong - Brown & Toland - in SF, finally got back to us on our request to have an out of network specialist do the myotomy surgery husband needs. They have refused to let us go out of network even though they have no in network specialist for the surgery. They referred us to 2 in-network MDs who they claim are " qualified " to do the surgery, but 2 of the MDs on the list aren't even surgeons. The other is a general surgeon, and the other a cancer surgeon. > > > > > > This is all the more crazy making because our insurance company - Blue Cross -- will cover the surgery if Dr. Patti does it, as they would consider him " in network. " > > > > > > I'm so angry and frustrated and scared. We are right back at square one with all this. Meanwhile, my husband is getting worse, losing more weight, looking more haggard, feeling more and more depleted. > > > > > > I had no idea before this how much power an HMO has in the process. For once, the insurance company is doing the right thing, but the doctors are hanging up my husband's ability to get the right care.The HMO has been horrible to deal with. everything has to go through the primary care physician's office. No email, no names, no phone numbers of anyone we can contact directly at Brown & Toland. Lots of smoke and mirrors, and we have no idea what to do next, There's some sort of appellate process but I'm not hopeful. > > > > > > Has anyone been in a similar predicament? Advice? > > > > > > Anyone know how much the surgery costs in the event that we decide to suck it up and pay for a specialist ourselves? > > > > > > Sorry for the rant. Just feeling so hopeless right now. > > > > > > Thanks, > > > in SF > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 27, 2011 Report Share Posted May 27, 2011 Reading your post really brought back the nightmare of funding this disease to us. My daughter was diagnosed six years ago at 12. At the time we were in private practice with minimal insurance. The insurance did not want to pay for dr snap at cal-pacific, chose the cheapest, not the best surgeon, and we had to wait several months for treatment. On the way to her surgery, blue cross called us to say they wouldn't cover her surgery. We remortgaged our house to pay the bill. Remortgaged again when she needed further treatment, went through our entire retirement savings, and finally my husband took a job at high desert state prison, 2 hours from home, to ensure her insurance coverage and rebuild our retirement. He is gone 4 days a week, working with murderers and pedophiles so she can have insurance coverage . Her last series of tests and dilation at cal pacific cost us out of pocket 2200 and that was with high end insurance. I feel for you. You will have to make some hard sacrifices, you are not alone. This disease defines the whole family, and you tend to pawn the future to pay for today. Helene Sent from my iPhone Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 27, 2011 Report Share Posted May 27, 2011 - I was in the same boat as u in 2009. Hmo in va didn't want us going to cleveland. And in the mean time my son became weaker and weaker. Horrible. U can read my experience posted in archives on this site from sept 2008 to feb 2009. We fought and with the help of the angels on this site we won! U will win also. Please search my archive..ANGELA BAKER...I capped everything because I was screaming too..problem with that is now I don't know how to uncap it. Haha. If u want to talk to me please e mail me at kotacj@.... I will send u my phone number. U will win. I remember I just kept telling the insurance company who was trying to force us to go with their inexperienced surgeon, I'm sorry we r not comfortable with that surgeon. They cannot make u comfortable u have to b comfortable. Not to say surgeon wasn't nice, he was. I wasn't comfortable with his level of experience in dealing with achalasia. Has he done 300 myotomies or more? If the answer is no then u may dear woman r not comfortable....angela Sent from my Verizon Wireless BlackBerry HMO Hell - advice? Hi everyone, I'm ready to scream and so is my husband. After months of waiting, the HMO to which we belong - Brown & Toland - in SF, finally got back to us on our request to have an out of network specialist do the myotomy surgery husband needs. They have refused to let us go out of network even though they have no in network specialist for the surgery. They referred us to 2 in-network MDs who they claim are " qualified " to do the surgery, but 2 of the MDs on the list aren't even surgeons. The other is a general surgeon, and the other a cancer surgeon. This is all the more crazy making because our insurance company - Blue Cross -- will cover the surgery if Dr. Patti does it, as they would consider him " in network. " I'm so angry and frustrated and scared. We are right back at square one with all this. Meanwhile, my husband is getting worse, losing more weight, looking more haggard, feeling more and more depleted. I had no idea before this how much power an HMO has in the process. For once, the insurance company is doing the right thing, but the doctors are hanging up my husband's ability to get the right care.The HMO has been horrible to deal with. everything has to go through the primary care physician's office. No email, no names, no phone numbers of anyone we can contact directly at Brown & Toland. Lots of smoke and mirrors, and we have no idea what to do next, There's some sort of appellate process but I'm not hopeful. Has anyone been in a similar predicament? Advice? Anyone know how much the surgery costs in the event that we decide to suck it up and pay for a specialist ourselves? Sorry for the rant. Just feeling so hopeless right now. Thanks, in SF Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 27, 2011 Report Share Posted May 27, 2011 Sorry to hear your issues. Try to make an appt to see his PCP, then tell him that the doc who is familiar with Achalasia is out of netwrk. What they do is write a referral to see those 2 in network MD's then those MD will refer you to the real doc who specialize with " A " . This is the only real good way to get paid in-network. Also did you ever try to call your insurance CASE MGR? Try to call your insurance PRE-AUTH area and explain your case but really your PCP shd be calling your insurance and explain that those 2 in-netwk docs are not THORACIC doc who does MYOTOMY.... Good luck! ________________________________ From: M. <lisa.anne.m@...> achalasia Sent: Fri, May 27, 2011 10:53:37 AM Subject: HMO Hell - advice?  Hi everyone, I'm ready to scream and so is my husband. After months of waiting, the HMO to which we belong - Brown & Toland - in SF, finally got back to us on our request to have an out of network specialist do the myotomy surgery husband needs. They have refused to let us go out of network even though they have no in network specialist for the surgery. They referred us to 2 in-network MDs who they claim are " qualified " to do the surgery, but 2 of the MDs on the list aren't even surgeons. The other is a general surgeon, and the other a cancer surgeon. This is all the more crazy making because our insurance company - Blue Cross -- will cover the surgery if Dr. Patti does it, as they would consider him " in network. " I'm so angry and frustrated and scared. We are right back at square one with all this. Meanwhile, my husband is getting worse, losing more weight, looking more haggard, feeling more and more depleted. I had no idea before this how much power an HMO has in the process. For once, the insurance company is doing the right thing, but the doctors are hanging up my husband's ability to get the right care.The HMO has been horrible to deal with. everything has to go through the primary care physician's office. No email, no names, no phone numbers of anyone we can contact directly at Brown & Toland. Lots of smoke and mirrors, and we have no idea what to do next, There's some sort of appellate process but I'm not hopeful. Has anyone been in a similar predicament? Advice? Anyone know how much the surgery costs in the event that we decide to suck it up and pay for a specialist ourselves? Sorry for the rant. Just feeling so hopeless right now. Thanks, in SF Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 27, 2011 Report Share Posted May 27, 2011 Dear Helene! We too have an HMO... Healthnet. They have been amazing. Cameron was diagnosed about 5 1/2 years ago. Like you on the way to our surgery the day before surgery, they called to say they would not authorize. Our specialist, and the Dr. we picked and pushed for... Cameron's specialist, Dr Patti, had an amazing assistant. He along with the Peds specialist from the UCSF children's called to have a telephone meeting with the board who makes the decisions for healthnet. They were more than happy to have that telelphone conference with our surgeon who explained to them the delicate nature of the surgery especially with a child, and of the long term results and costs including other courses of treatment and their viability. They relented and approved. They have never balked at the cost again. His surgery was well over $110K, due to complications. Anyone who is having problems with their insurance needs to know that they can be pushed to " insure " and provide for you. There are people who can help advocate for you regarding insurance. There are key words to be used by doctors, and there are newspapers, tv etc to help get them to cover you.. Additionally, you are entitled to at least 2 opinions. get at LEAST 2 opinions.. most insurance companies today insist you get 2! You are entitled to the best, no matter where he is, too!!!!! My code of motherhood is this.... " Don't mess with me.. and my child deserves the best medical care money can buy and insurance is gonna pay for it! " Carolyn Holmes mom of Cameron.. now celebrating 5 years of happy swallowing.. May 20, 2005 From: stovall.h@... <stovall.h@...> Subject: Re: HMO Hell - advice? " achalasia " <achalasia > Date: Friday, May 27, 2011, 11:10 AM  Reading your post really brought back the nightmare of funding this disease to us. My daughter was diagnosed six years ago at 12. At the time we were in private practice with minimal insurance. The insurance did not want to pay for dr snap at cal-pacific, chose the cheapest, not the best surgeon, and we had to wait several months for treatment. On the way to her surgery, blue cross called us to say they wouldn't cover her surgery. We remortgaged our house to pay the bill. Remortgaged again when she needed further treatment, went through our entire retirement savings, and finally my husband took a job at high desert state prison, 2 hours from home, to ensure her insurance coverage and rebuild our retirement. He is gone 4 days a week, working with murderers and pedophiles so she can have insurance coverage . Her last series of tests and dilation at cal pacific cost us out of pocket 2200 and that was with high end insurance. I feel for you. You will have to make some hard sacrifices, you are not alone. This disease defines the whole family, and you tend to pawn the future to pay for today. Helene Sent from my iPhone Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 27, 2011 Report Share Posted May 27, 2011 Haha amen sister...angela Sent from my Verizon Wireless BlackBerry Re: HMO Hell - advice? " achalasia " <achalasia > Date: Friday, May 27, 2011, 11:10 AM Â Reading your post really brought back the nightmare of funding this disease to us. My daughter was diagnosed six years ago at 12. At the time we were in private practice with minimal insurance. The insurance did not want to pay for dr snap at cal-pacific, chose the cheapest, not the best surgeon, and we had to wait several months for treatment. On the way to her surgery, blue cross called us to say they wouldn't cover her surgery. We remortgaged our house to pay the bill. Remortgaged again when she needed further treatment, went through our entire retirement savings, and finally my husband took a job at high desert state prison, 2 hours from home, to ensure her insurance coverage and rebuild our retirement. He is gone 4 days a week, working with murderers and pedophiles so she can have insurance coverage . Her last series of tests and dilation at cal pacific cost us out of pocket 2200 and that was with high end insurance. I feel for you. You will have to make some hard sacrifices, you are not alone. This disease defines the whole family, and you tend to pawn the future to pay for today. Helene Sent from my iPhone Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 28, 2011 Report Share Posted May 28, 2011 wrote: > > ... The HMO has been horrible to deal with. everything has to go > through the primary care physician's office. ... > In my case, I got approval to go see the out of network surgeon for a consult. I actually did that on my own. Then I decided to have the surgery there and went to may PC to get it set up. His office, with some input from the surgeons office dealt with the insurance to get approval. I also needed another manometry test by the surgeon which needed its own approval. A letter of approval came which seemed to be for the surgery though it wasn't clear. Remember that manometry and myotomy can sound a lot a like if you are not familiar with them. I was, but people we talked to on the phone probably were not. All indications from the hospital and the insurance company were that I was covered for the surgery. I wondered what happened to the manometry approval but not enough to pursue it. At the hospital, every time I was asked about the approval I showed them the letter and they copied the info from it and accepted it for the surgery. I woke up the next day after my surgery, still hooked up to a morphine pump, for a phone call asking how I wanted to pay the $30,000 for my " unapproved " surgery. More phone calls were made. Depending on who was asked, I had been approved, or had not been approved. Then we were told I was approved but it was not yet official but soon would be. A couple days latter a letter of approval arrived at home. It was a bit different form the first but still not very clear. The first letter was of course for the manometry test. The next shock was when the insurance company told us that $30,000 did not fit their ideas of Usual, Customary and Reasonable (UCR) rates and so they would only pay a fraction of the total. After a few months we found out that there was an insurance liaison person through work. She told us not to pay another cent and she got the insurance company to pay the total in full. > Anyone know how much the surgery costs.... It depends. Insurance companies get a volume discounts so what is " usual and customary " for them is often not the price you get or they get out of network where no volume is applied. Sometimes you can get a discount by bargaining with the hospital or surgeon before hand. You may get the same deal they give to insurance. Your cost may be as low as $10,000 or as high as $60,000 but if there are complications the sky is the limit. notan Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 28, 2011 Report Share Posted May 28, 2011 - I'm sorry you're going through this I can tell you my insurance was billed $25k for the entire procedure including the surgeon, but I can also tell you that my hospital stay was one day longer than it had to be. The surgeon said I'd be in 23 hours, I was in for 2 days. > > Hi everyone, > > I'm ready to scream and so is my husband. After months of waiting, the HMO to which we belong - Brown & Toland - in SF, finally got back to us on our request to have an out of network specialist do the myotomy surgery husband needs. They have refused to let us go out of network even though they have no in network specialist for the surgery. They referred us to 2 in-network MDs who they claim are " qualified " to do the surgery, but 2 of the MDs on the list aren't even surgeons. The other is a general surgeon, and the other a cancer surgeon. > > This is all the more crazy making because our insurance company - Blue Cross -- will cover the surgery if Dr. Patti does it, as they would consider him " in network. " > > I'm so angry and frustrated and scared. We are right back at square one with all this. Meanwhile, my husband is getting worse, losing more weight, looking more haggard, feeling more and more depleted. > > I had no idea before this how much power an HMO has in the process. For once, the insurance company is doing the right thing, but the doctors are hanging up my husband's ability to get the right care.The HMO has been horrible to deal with. everything has to go through the primary care physician's office. No email, no names, no phone numbers of anyone we can contact directly at Brown & Toland. Lots of smoke and mirrors, and we have no idea what to do next, There's some sort of appellate process but I'm not hopeful. > > Has anyone been in a similar predicament? Advice? > > Anyone know how much the surgery costs in the event that we decide to suck it up and pay for a specialist ourselves? > > Sorry for the rant. Just feeling so hopeless right now. > > Thanks, > in SF > Quote Link to comment Share on other sites More sharing options...
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