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Dealing with Medicare HMO and Colon Cancer

Posts: 1
Joined: Aug 2010

I wish I found these forums earlier.

This is regarding my grandmother who was recently diagnosed with colon cancer about 12 days ago from a colonoscopy. She is 77 with HMO medicare. She did not tell me about the reports until 10 days ago on a Friday night.

When I first saw the report 10 days ago I was panicking and frantic in finding a specialist available for her as I assumed time was very important. All the while hiding my tears and panic from her to keep her calm. The rest of her family are away and I am the closest relative.

Her primary care physician that she really trusts was on vacation and the substitute physician referred her to a General Surgeon Dr. P. I had called to receive the Authorization for Dr. P 10 days ago but unfortunately was not able to make an appointment on that Friday night. I was very angry when I called to the Dr. P's office as a person picked up but refused to open her scheduling book. I called over the weekend as well and same story. I had to call during normal business hours to schedule her in.

So I called my friends that are doctors and med students and they referred me to a colon specialist Dr. K and was able to make an appointment the following Monday. I was able to argue with the HMO to switch authorization to this specialist ASAP same day.

We saw the colon specialist Dr. K 7 days ago and he said he needs to operate on her and will put in an authorization from the HMO for the surgery. I asked him if she needed an oncologist privately so that I don't scare my grandma and he said he does not know until he operates. He said the authorization will take around 5 days.

After 5 days I found out that the doctors office have not even submitted anything yet to the HMO for approval after calling the various departments of the HMO. I was getting frustrated and angry at all the bureaucracy. I was able to push the doctors office to submit the form the same day Friday Night. It takes the HMO 2 days to review urgent approvals.

Fast forward to now which is today. I took my grandma back to her primary care physician (Dr. W) that just came back from vacation.

Dr. W was adamant in us seeing Dr. P instead of the Dr. K. My grandma thinks her primary care physician (Dr. W) is very credible and would listen to anything he says over anyone else's advice. So we now have to go through the process of HMO approvals all over again with Dr. P.

It will take 7 days before my grandma can see Dr. P as he is very busy. This was after our Dr. W spoke with the office directly to make this more urgent. I could imagine trying to schedule a surgery date with Dr. P.

When I first saw the report I was panicking in finding a specialist right away. But through research and friends I know that a few days will not hurt. But I also want to make sure I do everything I can so that my grandma can get what she needs fast without hurting her in the process.

What should I do to improve this battle with HMO? I am usually not this aggressive in pushing people to get things through bureaucracy but my grandma has cancer.

Thanks in advance.

Posts: 372
Joined: Aug 2006

Funny how the urgency curve seems to drop off if you not the one with cancer or the one trying to help a love one with cancer. Too bad there aren't more doctors who are cancer survivors. Nothing like having been there to understand the fear and the need to get help. My advice lean on them. Make it important to them they they get it done for you to get rid if you. Thus you bith get what you want. Good luck to your grandma and to you!

KathiM's picture
Posts: 8077
Joined: Aug 2005

The best suggestion is to accept that the PCP is the 'keyholder'. So, pick one, and make them your new best friend (PRIMARILY the insurance gal!). My PCP worked with me, sending me copies of each and every request for service, and then I could help them by calling the Healthnet myself. You need to get put onto her medical authorization list with Medicare...normally it is a form to fill out, and have her sign. Otherwise, they can refuse to speak with you. Do it now, before she needs you. It's a sort of Medical Power of Attorney.

Post here with questions, I'll keep my eye out for you. What a dear that you are stepping in to help your grandmother!

Hugs to you!


tesslee's picture
Posts: 97
Joined: Apr 2010

try a patient advocate. they will work with the caregiver or the person with cancer and coordinate needs. i worked patient advocate foundation when my avastin had not been approved yet and they told me it might take weeks. patient advocate did a conference call with me, my insurance, and them. they approved it that day. i was so impressed with them. and will use them whenever the need arise.

Lovekitties's picture
Posts: 3372
Joined: Jan 2010

All docs and hospitals these days also require a signed HIPA form which the patient must fill out saying who can be informed of the patients health, diagnosis, etc. and who can be made aware of their financial situation with that particular doc or hospital. If your grandmother does not put you on her list with these folks they cannot share any information with you per the health privacy laws.

Don't be afraid to push as hard as you need to push to get things moving, or to use others to do it for you. But make sure grandmother has given you legal rights or it will just slow things down.

Best of luck to you both and let us know how things go.

Marie who loves kitties

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