Tuesday, July 24, 2007

The problems with HMOs

We received a very disturbing letter today from Lorna's specialists. It seems Blue Cross and UCLA couldn't come to a contract agreement so they will no longer be accepting her insurance. I called the number on the letter to ask what we were supposed to do about her upcoming appointments, they had very few suggestions.

I called her primary doctor who said that we could get a special okay to see her doctors for the few things scheduled but then we would have to change specialists. The new doctors would be located 3 hours away in the other direction. I looked them up to find that they too couldn't come to an agreement so they are no longer accepting her insurance. I can't say I was at all calm. There are no other specialists within a 3 hour drive.

I called the insurance company who wasn't exactly helpful. Their solution was for us to put in for a special authorization for each appointment. They couldn't guarantee that they would accept the request, meaning at some point we would have to switch doctors and drive around 5 hours each way to see one of these specialists.

I was able to switch plans because of the extenuating circumstances. As soon as we have the new cards I can call the primary doctor to get us referrals to the UCLA doctors. I've already cancelled the special CAH clinic appointment in September. I did it before I found out we could switch midterm. I'm not all that broken up about it, I didn't feel right about going anyway. I have no idea what all of this is going to do to the tentative schedule for her surgery later this year.

All of this was caused because the doctors feel they aren't getting fairly reimbursed through Blue Cross. Looking at the charges and payments over the last few months I'm not sure who is right. $600 for a 10 minute office call with a pediatric urologist seems a bit much, only paying $120 of that charge seems a bit too little. The procedure Lorna had done as an outpatient was reimbursed at around 60%. That seems kind of low until you look at the charges. I just hope we can get the surgery done soon so the effects of any further changes in health plans won't be so far reaching.

1 comment:

elephantschild said...

Don't be too afraid to raise h#ll with the insurance company. It might be possible to get them to authorize anything you need to take care up to and including the surgery, and then make you change providers.

We had to go through special authorization for my jaw surgery in 2000. Thanks to a persuasive letter from my surgeon, pointing out that it WAS NOT being done for cosmetic reasons, the ins. coughed up the money.

My mom works in the insurance industry and would be the first to tell you it's totally and completely screwed up beyond repair.

Sorry. What a mess.