RE: CONTINUITY OF CARE

[Guest guest]

Unfortunately, it's been my experience that any HMO whether Medicaid or not

does not have to allow the patient to go out of network unless the service

required is not provided in their own network. Chances are the HMO does

have a transplant center in their state that they have a contract with.

Here in florida one HMO (Amerigroup) when I called on one of their patient's

told me they did not have a contract with any transplant center therefore

the patient was able to be listed and transplanted here. The other HMO's I

have dealt with send the patient to one of their contracted transplant

centers. Hope this helps, Pat

CONTINUITY OF CARE

A new question to all...

Patient had undergone a heart txp at our facility 15 years ago. Now, at

30 years of age, she needs a kidney transplant, borderline dialysis.

She resides in the neighboring state where she has an HMO Medicaid. She

is Medicare ineligible for ESRD - not enough working quarters. She has

been on disability, but never had Medicare. At the time of her heart

txp, as per patient's mother, Medicare based on diasbility under one of

the parents was not pursued because patient was fully insured under

dad's EGHP.

As per case manager, eval w/ possible kidney transplant was denied due

to non-participating facility and physicians. Negitiation is out of the

question and I tried to argue for her continuity of care, and still

denied. I am just waiting for the denial in writing to start the

appeals process.

Is anyone aware of any law that can relate to continuity of care for

this special case - 2 txps. I just can't believe that the HMO would

deny her transplant at our center. Is this legal ? Since she is

already established for a long time, I thought the HMO Medicaid would be

obligated to pay and will try to negotiate on a fee.

Any comments will be appreciated.

Thanks-

Sioson

[Guest guest]

My experience has been similiar--if an HMO (medicaid or not) has a contract with a payor in their state, then they're able to redirect and keep them where they're contracted to go. Fortunately, in 2 instances, I've been able to renegotitate (using the continuity of care arguement) to keep the patients here and work with the payor to do so. It hasn't been easy (much resistance on behalf of the payor) but it's worked out for the patient's best interest. The wonderful world of transplant!!!!!

RE: CONTINUITY OF CAREUnfortunately, it's been my experience that any HMO whether Medicaid or notdoes not have to allow the patient to go out of network unless the servicerequired is not provided in their own network. Chances are the HMO doeshave a transplant center in their state that they have a contract with.Here in florida one HMO (Amerigroup) when I called on one of their patient'stold me they did not have a contract with any transplant center thereforethe patient was able to be listed and transplanted here. The other HMO's Ihave dealt with send the patient to one of their contracted transplantcenters. Hope this helps, Pat-----Original Message-----From: Sioson Sent: Thursday, September 16, 2004 7:50 AMTo: TxFinancialCoordinators Subject: CONTINUITY OF CAREA new question to all...Patient had undergone a heart txp at our facility 15 years ago. Now, at30 years of age, she needs a kidney transplant, borderline dialysis.She resides in the neighboring state where she has an HMO Medicaid. Sheis Medicare ineligible for ESRD - not enough working quarters. She hasbeen on disability, but never had Medicare. At the time of her hearttxp, as per patient's mother, Medicare based on diasbility under one ofthe parents was not pursued because patient was fully insured underdad's EGHP.As per case manager, eval w/ possible kidney transplant was denied dueto non-participating facility and physicians. Negitiation is out of thequestion and I tried to argue for her continuity of care, and stilldenied. I am just waiting for the denial in writing to start theappeals process.Is anyone aware of any law that can relate to continuity of care forthis special case - 2 txps. I just can't believe that the HMO woulddeny her transplant at our center. Is this legal ? Since she isalready established for a long time, I thought the HMO Medicaid would beobligated to pay and will try to negotiate on a fee.Any comments will be appreciated.Thanks- Sioson

[Guest guest]

What if the HMO is a Medicare HMO?

We just recvd a new referral on someone with Kaiser/Medicare HMO secondary

to Cigna. She now lives in FL, so Kaiser does not cover her here.... my

thoughts are to advise the pt to switch from the HMO to straight

Medicare....correct?

CONTINUITY OF CARE

A new question to all...

Patient had undergone a heart txp at our facility 15 years ago. Now, at

30 years of age, she needs a kidney transplant, borderline dialysis.

She resides in the neighboring state where she has an HMO Medicaid. She

is Medicare ineligible for ESRD - not enough working quarters. She has

been on disability, but never had Medicare. At the time of her heart

txp, as per patient's mother, Medicare based on diasbility under one of

the parents was not pursued because patient was fully insured under

dad's EGHP.

As per case manager, eval w/ possible kidney transplant was denied due

to non-participating facility and physicians. Negitiation is out of the

question and I tried to argue for her continuity of care, and still

denied. I am just waiting for the denial in writing to start the

appeals process.

Is anyone aware of any law that can relate to continuity of care for

this special case - 2 txps. I just can't believe that the HMO would

deny her transplant at our center. Is this legal ? Since she is

already established for a long time, I thought the HMO Medicaid would be

obligated to pay and will try to negotiate on a fee.

Any comments will be appreciated.

Thanks-

Sioson