I'm faced with a big, big dilemma regarding my HMO insurance. I was hoping maybe you could offer me some advice. 3 years ago I sustained an injury and doctors prescribed creams to heal this injury; however, I developed a severe allergic reaction to these creams, and resulted in a medical condition that now causes me to have chronic on-going pain. I have been suffering with this chronic pain for over 3 years and I've seen well over 20 doctors who have no idea what to do. My HMO wants me to stay inside their network, but they want me to go to a "specialist" who has never treated anyone with my condition before. I do not trust them. I realize that I cannot get the real proper care that I need within my HMO network. Therefore, I found a specialist on my own research. I've arranged appointments with this specialist; however, the problem is he's in Washington, DC and my HMO refuses to pay for any of these bills. I've also been advised by him that I need surgery to correct my chronic pain. I went back to all the doctors I've seen and asked each of them to write me a letter of recommendation. The reactions I've gotten ranged from avoidance to skepticism ("What good is that gonna do?") to hostility ("This is a waist of time"). I have no letters of recommendation to date, which would really help me in my appeal process.

My surgery is scheduled in Washington, DC for 11/25/03. My HMO is refusing to pay for my surgery done by him, even though it is NOT cosmetic. My HMO further refuses to cover any of my pain medication prescriptions--Can you believe that? I'm looking at a $16,000 out of pocket expense here. I don't have deep pockets; I'm a starving student with student loans from another university to worry about, and a part-time job that's not financially lucrative.

I feel cornered and trapped. I feel just like John Q! Here I am constantly paying money to have insurance coverage but they refuse to pay for a needed surgery. I just don't know what to do. I've also looked into getting a PPO but they have restrictions as well. Plus I calculated that it's going to cost me even more because I have to pay them $500/month plus my deductible, and I'm responsible for 100% of doctor's bills and 30% of the hospital bill. I figure I'll just get another loan, pay it out of pocket, and then claim it as tax credit. Do you think that's a good idea? Or do you think it's worth it to fight my HMO? Have you ever fought with them before? It seems like a nightmare and this is only the beginning for me! I haven't had surgery yet and they're already giving me the trivial run-around.

I appreciate your time and any advice you could offer me. Again, thank you so much!

Do you have a primary care physician? He would be the one to approach about getting the letter of recommendation.

I used to work in a primary care office, and occasionally we would have a patient we would have to send out of network for whatever reason. We never had any trouble.

As for the pain medication, if the PCP is writing it, I'm not sure why it is not covered, as well as the physician bills for the out of network physician.

All of this being said, if you are going to someone who is truley doing a surgery/treatment that is expirimental and outside the mainstream of medicine, this could be the reason you can't get a referral and for your lack of cooperation from in network physicians. I'm not saying that this is bad medicine, but your contract with the HMO probably excludes expirimental medicine, so you'll have to decide if this is a worthwile expense.

As for pain treatment, there is a significant debate as to weather long term pain medication, especially in a young person, is effective. Often it alleviates the pain, but the side effects leave the person every bit as disabled as the pain did. You may want to ask your PCP for a referral to a pain management doc.

Thanks a lot for your input; much appreciated! My PCP absolutely refuses to help me. I've only seen him once, and when I told him the condition I have, he started talking about motion sickness (that's not what I have, totally off! He is completely clueless). So I asked him to refer me to a vulvar specialist, which is what I need. He gave me an ob/gyn number who doesn't treat the condition I have. I called my PCP back again and asked once more for a referral to a specialist. They gave me another ob/gyn who told me they can't help me. I called again, very upset, to my PCP and once again they gave me this number assuring me it's a true vulvar specialist but it turns out just to be a regular ob/gyn. I asked if they were specialists because my PCP said they were, but they said no. I got fed up with it! So I called Blue Shield and switched to another PCP, just any name from their book. It was a 30 day wait for it to go into effect. In the meantime I was in so much pain, I really needed to see a competent doctor. I called in sick almost everyday at work, I ended up getting fired. Well, when I finally could see my new PCP, he also had no clue what to do with me. He referred me to yet another ob/gyn. I gave up at this point since I could see that I was going nowhere and just getting the trivial run-around no matter who I went to. That's why I did my own research and found a specialist. Whenever I call my PCP for a letter of recommendation, I can't get him on the phone. So I told his secretary many, many times to put it in writing that this doctor does not know any specialists. The secretary told me he doesn't do that. I have no idea why. By that time I became really mad and they got hostile with me as well. They told me the same thing: I can go ahead and change to a different PCP if I wish. OMG.
I went to the doctors I've seen already, many of them when I was uninsured. They, too, refuse to help me. They tell me their letters won't carry any weight and that it's a total waist of time. Basically I'm completely on my own here. But I'm not giving up.
I can't believe all my doctors are giving up before I am.
Help!

sorry- i forgot to respond about the surgery: it is not experimental. My doctor in DC performs it everyday. Over 100,000 women in America have had it done to cure chronic vulvar pain. There is no insurance code for it - a vestibulectomy. Defintely not cosmetic, and vestibulectomy is a pathology but unfortunately not many doctors know what it is or what to do about it.
Thanks. Any more advice is very much appreciated!

You're probably right, the PCP didn't know what to do with you, but here is where the breakdown did occur.

The OB/GYN, even if he wasn't the one who could treat you, would know who you need to see, and could provide the letter of referral that you need. For instance, we had patients that would have eye problems, and we would send them to an opthamologist. Often he would send them to a virtro-opthamologist at a university. On rare occacion, that specialist may send them to one of the 5 or so neuro-opthamologists (neurosurgeons and opthamologists) in the country.

Those ultra specialists are in network with nobody, but because they had their ducks in a row, the patients usually had no trouble getting their visits and surgery covered.

At this point, your ins. co. will not cover you without a letter of referral from an in network physician. The best way to get this will probably to go ahead and see an OB/GYN, and ask for that from him, or ask for a vulvular specialist from him. Although this guy may be great, the network may have another vulvular specialist in network.

As for dealing with the OBs office, an OB is certainly the main specialist for the vulva. Their are certainly subspecialists out there, but even the doctor you are seeing now probably has his Board certification in OB/GYN.