Insurance what to do?

[admin]

As many of you know Desiree is schudle for sugery
wed the 12th just now the insurance tellingme they might
not cover that it will be heard in fron of the medical directory of trigon healthkeppers tommrrw there saying
that it is out of state it is out of my network and
I have to go to VA since I live there and there is
doctor's that can do it here I 've heard of doctors here and hav't heard much good out of none of them my nurgeliost is the one that suggested texas and what of
seen form this web site they seem to be the best have my airline tic and hotel already paid for and now there telling me it might not happen.
Has this happen to anyone and is there anyway to gey around it or might help please let me know if anyone
nos of anything
Thank you Jeannine Desiree mom

[Joann in PA]

Dear Jeannine, Just wanted to give you a word of encouragement. Joey had his first surgery 4 years ago. Our hmo denied us at first and said we could have the surgery done here in Pennsylvania. We talked to the surgeon they were recommending and he himself agreed that TCH was the place to go and sent our hmo a letter. They ended up approving it and Praise the Lord have approved the subsequent surgeries as well. Perhaps your neurologist could send them a letter. Getting through all those hurdles and facing the unknowns from the first surgery etc is so so stressful. Try to take it one day at a time yet be firm and resolute. God bless.

[TNT1999]

Hi, Jeannine. I suggest that you contact your state Attorney General's office right away -- the area that deals with insuranc problems and see ift hey can help you. You should also findout who are the in-network drs who are qualified and contact them. In order for you insurance co. to consider your appeal to go to TCH though, you might have to actually at least see the in-plan dr(s) though. Sorry, but I don't remember how old Desiree is. She's scheduled for primary, right? If so, there is a very limited timeframe for that surgery and by contacting one of the other surgeons even by the phone, maybe you could get one of them to sympathize with your case and write a letter stating that primary nerve surgery has to be done within a certain time period and that they wouldn't be able to perform the surgery within the optimal period and that they recommend that you go to TCH. (something to this effect) We were somewhat successful wih our appeal to have primary surgery covered at TCH. One more thing, not to worry you, but we were told that if we went ahead with surgery and it had NOT been approved, then even if they would've overturned their decision, they still wouldn't have to pay for it if we had it done PRIOR to them approving us. It's a difficult decision and you just have to weigh everything -- how old Desiree is, what procedure you're planning to have done, how strong your case is, who the inplan doctor is, etc. etc. Oh and you might try calling the dept. of insurance in your state. Also, if possible get any local inplan drs. to write letters stating the medical necessity for you to go to TCH. Well, I hope this helps. I can emphasize with you and know that it stinks to have to deal with this stuff aside from all the normal pre-op stress. Take care. -Tina

[Mary]

Jeannine, find out what it takes to go out of network, follow their rules but when push moves to shove, stand your ground. Make sure to get all the recommendations from your doctors in writing because although they do send them to the insurance company, it doesn't hurt to have them yourself in the event you are on the phone with someone who needs a copy of a letter faxed to them. Call your state insurance commission. They usually will either do some of the leg work for you or give you the name and number of someone at the insurance company that can help you. Does your state have a secondary insurance program? Our state doesn't but I have read other posts from families that live in states that do. There should also be someone where you get your insurance (employer) that may also have a phone number of someone else at the insurance company that can help you. We recently had a similar issue but with physical therapy. It is not an easy fight and you have to stay strong. If your neurologist, who is one of the insurance company providers, has recommended Texas, ask the insurance company why they seem to have no regard for the opinions of the doctors in their network. I wish you the best of luck. I hoped this helped.