HELP! With Insurance Problem

dsignrvinyl · 08-11-2009, 01:58 PM

Does anyone know of a way to get these Big Hospitals That own their own Insurance Companies to let patents get Out of Network Referrals when all in network options have been exhausted? To me this is a MONOPOLY! My Primary Care Provider had sent a 69 page Report to the Insurance Provider explaining that all In Network Providers have been exhausted and the need to go Out of Network to help me get surgery to help relieve my condition. In the Report it has Referrals from my PCP, Pain Specialists, Physical Therapists, Neurologists, Podiatric Surgeons, etc. No One in the In Network Provider Find a Dr. Can or Will do the Surgery I need.Of the 2 Insurance Providers Doctors that reviewed the Case and Denied the Referral, 1 Will NOT Provide any In Network Providers and The 2nd Gave me 2 In Network Podiatric Surgeons that do not perform the Surgery. He himself is a PODIATRIC SURGEON and does not do the Surgery. They all know of the Surgery, know the Success Rate, but none are Trained to do the Surgery. They keep sending me on Wild Goose Chases,spending Insurance Monies, not only Theirs but Medicare funds, My money on Co Pays, etc. I am at my wits end. The Pain I have is Excrutiating! I have a Surgeon that is offering a 75% reduction in Pain with an 80 to 90% Success Rate and they Still Refuse to go out of Network. Although in 2001, when I got a MRSA STAFF INFECTION from One of the IN NETWORK Hospitals from a Simple Hip Replacement Surgery, The Surgeon that did the surgery left the Practice so I got sent to 5 In Network Surgeons and ALL REFUSED to do the REPLACEMENT SURGERY and I got an OUT of NETWORK REFERRAL to go to the CLEVELAND CLINIC to fix their mistake. They Issued the Out of Network Referral IMMIEDIATLY with no Problems. Makes You kind of wonder? I hope someone can help with my problem.

SpineAZ · 08-17-2009, 12:22 AM

Do you have the option of using an out of network provider and perhaps paying a higher copay or co-insurance amount? I had both my neck surgeries done by an out of network physician. It cost a bit more but I was aware of that. You can often do this with a PPO or POS . HMOs tend to be more restrictive, thus I never choose them.

dsignrvinyl · 08-17-2009, 08:52 AM

The Health Plan tells Out of Network Dr.'s & Facilities that I have NO Out of Network Services but I know that is false because I have had to go out of Network on 5 different occasions. Twice to replace a hip because I got a MRSA Staff Infection at of one of the In Network Hospitals. 5 different Surgeons REFUSED to do my replacement surgery. They had no problem authorizing my Out of Network Surgery. Twice I went back to the out of Network Facility to put my hip back into the socket because the facility closest to me could not put it back in. Then I had to go out of network for a simple heart cath. The insurance company gives the option of the HMO or PPO but the PPO is priced so high that only 10% can afford it. The HMO DICTATES who you can see, even when there are NO In Network Dr.s that will do a surgery. I finally got my Auth. when I contacted the White House, The Attorney General, The Pa. State Insurance Comm. Complaint Hotline and The Office of the Health Plans Medical Director. Then I got all kind of Dr.sand even the Med. Director aand they authorized me to go out of network to a specialist. This University Hospital Group and Insurance Company have a MONOPOLY and the Attorney General have had a lot of Complaints against them plus Multiple Lawsuits from area Hospitals and 2 of the Major Ins. Companies.

SpineAZ · 08-17-2009, 02:27 PM

I'm confused as to what type of health insurance you have. I wasn't aware of insurance companies that own hospitals. I have seen that some hospitals self-insure their own employees and thus manage their plan differently than standard insurance - but usually utilize an insurance company or third party administrator to manage the plan.

Get a copy of the exact plan under which you are covered (the entire document). It will detail all of your benefits. And, if you want to see someone out of network you contact that provider and give them your insurance information. They will then contact the insurance company to verify benefits.

When I wanted to see the out of network orthopedic spine surgeon I just called them and gave them my insurance information. They advised me that "Dr. X is out of network so therefore we estimate your costs to be "X" for your initial visit and you have a 30% co-pay after you meet your annual deductible". When I went in to see him I had to sign an agreement saying I was aware of the extra cost and that he was out of network.

If you do have an HMO it can be very very restrictive (this is why I advise people never to choose HMO coverage if they have a choice, even if a PPO or POS plan costs more per month in premium it is well worth it.

If you have insurance through your employer they may have an annual re-enrollment in which you can change plans and when this occurs you may want to consider doing so.

dsignrvinyl · 08-18-2009, 08:38 AM

The Hospital owns the Insurance Company not the other way around. I went to the Out of Network Surgeon for a consult. His office scheduled surgery for me. When his office contacted the Insurance Company about an out of network authorization, they were told that I had NO out of network benefits which is untrue because I have the original booklet sent by the insurance company on my policy benefits and Nowhere does it say that I have no out of network benefits. In fact it tells you how to apply for them. The surgeons office was also told that if the insurance company does not pay, my secondary insurance will not pay. This I know to be false because I called my secondary insurance and they told me that this is not true because they determine what benefits they pay on a case by case basis. Not just because my primary ins. does not pay. My primary insurance company does not only offer ins. coverage to just its employees but to many of the companies in the area. They have lawsuits against them from 3 major insurance providers in the country plus many of the only independantly owned hospitals left that the University Hospital hasn't gobbled up. The University Hospital has a MONOPOLY in this area. They just have some very good attorneys to put a lot of Loop Holes in the system to get around that fact. The PPO they offer can only be afforded by the top Excecutives and the Doctors.