Working with Insurance

[Guest guest]

Hi everyone,

I need to run this by some of you and get your opinion. I hope this makes

sense. I'm in the process right now of working with (we have been denied)

our insurance for approval for a consultation with Dr. Reinisch at Los

Angeles Children's Hospital. It is really working into a big fight, so far

our pediatricians office is being very helpful. I have it in me to fight for

this, however I'm pretty sure (99.9%) sure that we will not go this route and

go with Dr. Brent. I just feel I want to research and consult a doctor for

both procedures. I figure I can fight for this now and then fight for Dr.

Brent in a couple of years? For those of you with experience in going up

against the insurance companies, is this worth the fight? Should I just save

it for Dr. Brent? What are my rights (at this point I don't feel I have any)

to consult on both procedures?

I hope this made sense??? A this time they have referred me to a run of the

mill plastic surgeon who I doubt has ever performed microtia reconstruction.

[Guest guest]

First of all, you need to actually visit the guy they recommend. This is

necessary to put together the ammunition you need to prove that the dr. is

not competent to perform the microtia repair.

Half the time, the doctor you are referred to will actually say " I shouldn't

do this surgery, Dr. Brent should do it " . If you can get him to do that in

writing, then I would use that to immediately force the insurance company to

give you a referral to Dr. Brent. Patty's ENT (Dr. Roberson) says one of

the drawbacks of being in Palo Alto is he hasn't gotten to do a microtia

repair (surgery he loved to do) since he finished medical school because

everyone in this area who wants a rib graft repair goes to Dr. Brent :-)

However, you are in the somewhat complex situation that you already asked

for the referral to Dr. Reinisch and were denied. You don't want to give up

on this denial, because let's say (this is a very depressing hypothetical,

but after all that's what they teach you in law school) Dr. Brent gets run

over by a car and you decide you want Dr. Reinisch to do the surgery after

all. You then have an uncontested denial on the books which is harder to

overcome.

So, here's my recommendation:

1) Go for a consultation to the Dr. they recommended. Ask all of the

questions Dr. Brent told us to ask (how many of these have you done? what

is your complication ratio? can I talk to people you have operated on?,

compare and contrast graft vs implant? etc.)

2) Send the insurance company a letter basically saying that you are going

to see the other Dr., but you are preserving your right to appeal the denial

to see Dr. Reinisch, and that you are also interested in seeing Dr. Brent

because you have not yet determined whether the implant or rib graft repair

is the best option (stretching the truth, but it suits the circumstances)

3) Ask them how long you have to appeal the denial to se Dr. Reinisch

(usually it is 60 days, but double check !).

4) Push the insurance recommended Dr. to go on the record as for Dr. Brent

or Dr. Reinisch. Bring copies of their web site pages to the appointment in

case this guy is so clueless he doesn't even know who they are.

Presumably you can get in to see this guy before the time for appeal is up,

and then you have more material to appeal on.

I will be out of town next week, and won't have reliable e-mail access, but

I will be happy to help you with the letters, etc. when I come back if you

need help

Sheri

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