United Brachial Plexus Network, Inc.

My son Demare will be having his surgery July 21st at Memorial Hermann's Children Hospital with Dr. Nath. I was wondering if there's anyone out there who can give me advice as to how I can go about getting his surgery paid for by my insurance company, if that's all possible. We have Blue Cross HMO and live in California. I know there's a way of having it done, but do not know how to go about it the right way. Please help! Thank you!

Clarissa

How about contacting the California bpi support groups and seeing if anyone else has your same insurance?

Also, Call Brenda at Dr. Nath's office and see if she knows if anyone else who has come to him has used that insurance. I'm sure he has some good medical necessity letters he's used for people with tough insurance issues.

You didn't mention what surgery it was. Is it something that specialists in your area don't do - that would also be helpful. Best of luck.

Get a referral from another Dr. stating there is no one in your insurance network that deals with this type injury.

I just went throught this process. When I had to pick my insuruance in 2003 for 2004, I consulted a personal contact at the insurance company, I asked her whether I should pick the PPO (Provider network with an out-of-network provision, but limited therapy coverage) or the HMO (with no out of network benefit, but more generous therapy coverage). I also new that my child would most likely be having (out of network)surgery in 2004.

Guess what she recommended???? She said to select the out of network HMO plan. Why? Because the therapy visits are part of the "core" treatment and would have much utilization. So, what about the surgery you may ask?

Here's the little secret. If we selected the PPO coverage and went out of network we would be responsible for a 30% copay. At $25,000, that's a hefty $7,500 out of pocket. If we selected the HMO and there was no doctor in their network who could perform the surgery that was needed, the insurance company would pay the entire surgical bill!!! Sound too good to be true? It's not, it happened, we did it!!!

Here's how - we contatcted the insurance company by calling the customer service number on the card. We explained our situation and were assigned a case manager. We provided the case manager with some information about the injury and the way it is treated. In our situation, we used Dr. Nath for a mod quad and pointed the case manager to his web site. She gathered information and reviewed it with the company's medical director. We stayed in touch with the case manager and in about a week they approved it!!!! If it wasn't approved our plan was to try to appeal it. After that, we would have contacted our state insurance commissioner.

Good Luck!