HMO and out-of-network coverage

Help4Sis
Help4Sis Member Posts: 53
edited March 2014 in Breast Cancer #1
Has anyone here had any luck getting approval to be treated in an out-of-network cancer center? My sister was (2nd sister in 10 years) diagnosed last month. Is trying to get treatment in an out-of-network center with WAY more experience than the local or other in-network centers. Is she just chasing her tail? Or can she actually win this appeal? Thanks in advance!

Comments

  • MNLynn
    MNLynn Member Posts: 224
    #2
    out-of-network
    I don't know if I can be of much help with this . . . if she goes to an "out-of-network" place, would she be paying a higher amount, or would her insurance not cover anything (unless she can talk them into it)? I would definitely want to be at the place where I felt I would be getting the BEST care!

    I was unhappy with the first surgeon I talked to - and within hours, was already talking to someone at a different cancer center where I did end up getting my care - so glad that I did that.


    Do you think the American Cancer Society site may have some links to someone who could help with pursuing that?

    Hope she gets to the place where she feels that she is getting the best care possible.

    With thoughts & prayers,

    ♥ Lynn ♥
  • KathiM
    KathiM Member Posts: 8,028 Member
    #3
    Yes, first for my bowel resection, then my lumpectomy....
    I have Healthnet HMO....

    Actually, I got my doc to put in a referral request. It was worded in such a way that it sounded like this was a specialty, that no one in my network could do. Then, it was sent STAT. And they didn't respond for 3 days. When I called, I called attention to the STAT check, and said "you are already in violation. I need an approval or rejection today so that I can decide what to do. I will say that, should you reject, I will be sending an appeal to HealthNet umbrella company, and I will certainly be pointing out your delay."

    I got a call 2 hours later that it was approved. It helped that the hospital/surgeon I wanted was already contracted with HealthNet, just not my group...

    I do need to say that I tried to be treated completely outside my insurance by City of Hope. When I spoke with a gal there, she said that even if I was denied by my insurance, the first round of treatment is pretty much the same anywhere. She suggested that maybe I should save my fight for out-of-network for the second time around, should I need it. She said that that is where they really shine...I took her advice, and the fight I fought was for my surgeon, who specialized in low bowel resection...I could prove that no one in my network could perform the same procedure.

    Good luck to sis!


    Hugs, Kathi
  • Help4Sis
    Help4Sis Member Posts: 53
    #4
    MNLynn said:

    out-of-network
    I don't know if I can be of much help with this . . . if she goes to an "out-of-network" place, would she be paying a higher amount, or would her insurance not cover anything (unless she can talk them into it)? I would definitely want to be at the place where I felt I would be getting the BEST care!

    I was unhappy with the first surgeon I talked to - and within hours, was already talking to someone at a different cancer center where I did end up getting my care - so glad that I did that.


    Do you think the American Cancer Society site may have some links to someone who could help with pursuing that?

    Hope she gets to the place where she feels that she is getting the best care possible.

    With thoughts & prayers,

    ♥ Lynn ♥

    Thanks for your reply.
    Thanks for your reply.

    There will be no coverage for out of network unless they give approval.

    She just signed up to speak with a rep from the Patient Advocacy Foundaton. Hope to hear from a case manager tomorrow. Hopefully, they will be able to steer her.

    Unfortunately, it has now been 4.5 weeks since diagnosis and she has to get moving. Her primary care physician will do anything to help and has sent in the referal requests. If she doesn't get this through within the next week, she will have to see what her next option is.

    Thanks again, Linda
  • Help4Sis
    Help4Sis Member Posts: 53
    #5
    KathiM said:

    Yes, first for my bowel resection, then my lumpectomy....
    I have Healthnet HMO....

    Actually, I got my doc to put in a referral request. It was worded in such a way that it sounded like this was a specialty, that no one in my network could do. Then, it was sent STAT. And they didn't respond for 3 days. When I called, I called attention to the STAT check, and said "you are already in violation. I need an approval or rejection today so that I can decide what to do. I will say that, should you reject, I will be sending an appeal to HealthNet umbrella company, and I will certainly be pointing out your delay."

    I got a call 2 hours later that it was approved. It helped that the hospital/surgeon I wanted was already contracted with HealthNet, just not my group...

    I do need to say that I tried to be treated completely outside my insurance by City of Hope. When I spoke with a gal there, she said that even if I was denied by my insurance, the first round of treatment is pretty much the same anywhere. She suggested that maybe I should save my fight for out-of-network for the second time around, should I need it. She said that that is where they really shine...I took her advice, and the fight I fought was for my surgeon, who specialized in low bowel resection...I could prove that no one in my network could perform the same procedure.

    Good luck to sis!


    Hugs, Kathi

    Thanks, Kathi, for your
    Thanks, Kathi, for your reply. She has sent her requests in as expedited requests and also put in her request that, 'any delay in answering will be a serious risk to her health.' Hoping that will get them moving. Has already filed an expedited grievance also.

    Thanks again for your reply!

    Linda
  • MNLynn
    MNLynn Member Posts: 224
    #6
    Help4Sis said:

    Thanks for your reply.
    Thanks for your reply.

    There will be no coverage for out of network unless they give approval.

    She just signed up to speak with a rep from the Patient Advocacy Foundaton. Hope to hear from a case manager tomorrow. Hopefully, they will be able to steer her.

    Unfortunately, it has now been 4.5 weeks since diagnosis and she has to get moving. Her primary care physician will do anything to help and has sent in the referal requests. If she doesn't get this through within the next week, she will have to see what her next option is.

    Thanks again, Linda

    I hope . . .
    that things go good for her - glad she has someone from an advocacy group to help. Please let us know how she is doing - and let her know that we are keeping her and all of you in our prayers.

    ♥ Lynn ♥
  • deeb111
    deeb111 Member Posts: 141 Member
    #7
    hmo
    HI Just tell your sister to find a doctor in her network that might also work in this facility and the doctor can tell insurance company this is most experienced facility to handle her case sometimes this helps cause the doctor say they want particular centers or hospitals or sometimes center will just accept out of network coverage but you also should call insurance get supervisor and plead with them tell them your life depends on this

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