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Insuranc paying for HCM specialist out-of-state?

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  • Insuranc paying for HCM specialist out-of-state?

    [Insuranc paying for HCM specialist out-of-state?]

    Author: Karla (---.proxy.aol.com)

    Date: 06-26-02 22:52

    Hi, All

    Would like to hear from any of you out there that have trekked out-of-state to see an HCM specialist, and if you had any luck in getting your health insurance to cover the 'out-of-network' visit.

    Is there a 'good' approach to use with the insurance company?

    Also, is there usually an extraordinarily long waiting period of several months to get an appointment with an HCM specialist? ('xscuse me if that's a silly question!)

    Thanks!

    Karla

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    [Re: Insuranc paying for HCM specialist out-of-state?]

    Author: Lisa Salberg (---.dyn.optonline.net)

    Date: 06-27-02 07:44

    Your insurance plan should spell out in the plan document what is and is not covered. Plans vary - HMO - PPO - POS - indemnity- and a few other choices. Sometimes you will need a referal and rarely you will have a problem getting them. However if you are with an HMO you have rights under the patients bill of rights that will allow you to contest the HMO's Denial of a referal/treatment.

    This can get a little trick... but I am more than happt to assit you in getting to the bottom of the insurance mess - so call the HCMA office and we can discuss your case in detail.

    Also re specialist, depending on the center the wait is not that long - max 8 weeks, sometimes it can happen very fast ( I know a woman who was from the deep south who happen to be going to NYC and arranged an appointment within 3 days!)

    All the best,

    Lisa

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insuranc paying for HCM specialist out-of-state?]

    Author: Board Moderator--Sarah Beckley (---.dsl.mindspring.com)

    Date: 06-27-02 13:35

    Hi

    My personal experience was that after a nightmare experience with an HMO, I changed to a PPO and will never go back to an HMO again.

    However, I did have one snag when I went out-of-state to my specialist on my PPO. There is this thing called "re-pricing." When a hospitals bills an insurance company the first time, it is the maximum amount they think they can get away with. If they have a contract with the insurance company (IC), the IC then sends it back to the hospital to be re-priced (aka discounted). Then the hospital sends them an adjusted bill and the IC will pay most of that and then stick you with anything left over until you meet your out of pocket cap (which is usually 2-3K). (Please excuse my bitter, jaundiced choice of words.)

    Well, I live in Illinois and my doctor is in Minneapolis and the IC had a contract for re-pricing for both states --but only if _I lived_ in Minneapolis. Since I didn't live in MN, but the doctor did, the IC assumed I lived in MN and kept sending the bill back to be re-priced (like three or four times) with no one bothering to see why it wasn't getting discounted. And the hosptial kept denying the request to discount because they didn't have a contract to do so. I finally had to call a manager at the IC and she had to go walk over to someone's desk and make them pay my bill. But they did.

    When I talked to the IC customer service people over the phone, I asked how many times they asked for re-pricing before they gave up and she wouldn't answer me and wasn't helpful at all, which is why I went back to my HR dept. and asked them to step in --they gave me the number of the manager to talk to who fixed it.

    I share this story in case any other out-of-state visits get this kind of run around.

    Sarah

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    [Re: Insuranc paying for HCM specialist out-of-state?]

    Author: rhonda (---.proxy.aol.com)

    Date: 06-28-02 01:01

    I think I am the woman that Lisa is referring to from the south w/ an appt made in 3 days. Dr Sherrid in NYC and the office staff were very flexible and even rearranged to move the appt up so I could make my return flight.

    as far as insurance- I have bcbs personal choice. all i needed was a referral from my primary health provider and they paid 70 % of the bill. I was truly surprised but it

    worked for me. I still had about 600 dollars out of pocket expense but well worth it to get the specialist opinion.

    good luck

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insuranc paying for HCM specialist out-of-state?]

    Author: Board Moderator--Sarah Beckley (---.dsl.mindspring.com)

    Date: 06-28-02 01:46

    Yeah, as for time frame, it only took me two weeks to get in to see my specialist. And I was basically a walk-in (I wrote a letter explaining my situation b/c it was very complicated and I would have messed it up over the phone). They called me when they got it and said come on by!

    S

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    [Re: Insuranc paying for HCM specialist out-of-state?]

    Author: Jerry Salzman (---.indy.rr.com)

    Date: 06-28-02 09:17

    Karla,

    I have a HMO had I do want to go to a specialist and get a second opinion. I talked to my primary care doc last night and he is going to talk to the medical director to see if they will approve it. He thinks I would have a decent chance for a consult since we could send all the tests results. Whether they would pay for surgery if that is the decision, I do not know. There are doctors who do both ablation and myectomy here in Indianapolis but with limited experience and in the older population.

    Truefully, this HMO is very good. They approved my ICD for prevenitive reasons in January 2001. I will let you know next week if they approve the concultation.

    Jerry

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    [Re: Insuranc paying for HCM specialist out-of-state?]

    Author: john jordan (---.public.svc.webtv.net)

    Date: 06-28-02 09:50

    hi karla, i have blue cross/shield pos, i received permission to consult specialist at cleveland clinic and i live in pitts pa area. my cardiologist pushed for this for me. i also have approval for surgery, myectomy, one or two valves, 2 bypasses. the only thing not approved was echo the surgeon wants done there, i will have to pay dedutible and 80% it seems. the surgeon insists the echo be done by his tech before surgery. the insurance approved seeing staff cardiologist as well as the surgeon a week before the operation. it did requre a lot of phone calls between, cardiologist office and primary care dr. and me of course. what do older people do to deal with all this. good luck, john

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insuranc paying for HCM specialist out-of-state?]

    Author: Lisa Salberg (---.dyn.optonline.net)

    Date: 07-01-02 18:44

    Rhonda - Yes you are the woman I was refering to!

    John - How are you doing, are you ready for your procedure?

    Jerry - Thanks for the input on a "good" HMO - dont hear that one enough!

    and ...

    Karla - sounds like you have some great input, let me know if you need anything further.

    Best to ALL!

    Lisa

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Insuranc paying for HCM specialist out-of-state?]

    Author: Karla (---.proxy.aol.com)

    Date: 07-01-02 22:53

    Thanks, All....

    ....great input from the boards...(as per usual!) I think our primary care physician will be accomodating with the referral. He spent quite a long time with hubby last visit and we told him we were not happy with our current cardiologist. He gave us a referral to another one here locally...(I think it's pretty much a waste, but hubby wants to see someone else here before making the trip o Cleveland - why I don't know!) I still don't think he understands how much HCM is a 'subspeciality" within a "specialty"(using your words, Lisa)

    Our finances are not the best as of late, and I think he has money 'worries' on his mind more than his health!

    still plan on pursuing seeing Dr. Lever in Cleveland as suggested. Gathering up copies of reports/tests to take with us and let Dr. Lever advise.

    Thanks again! Best to all!

    Karla

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    [Re: Insuranc paying for HCM specialist out-of-state?]

    Author: Board Moderator--Sarah Beckley (---.dsl.mindspring.com)

    Date: 07-02-02 00:52

    Dear Karla

    Most special heart centers are very understanding of the the insurance situation people are in and it would probably ease hubby's mind if you called the Clinic and talked to them about how they handle the insurance, the bills, etc. Even if you are in an HMO, there is always (I believe) an out-of-pocket cap on what you have to pay each year. (Your insurance co. can tell you what this is --it is not the same as a deductable.) So in the year I racked up $70,000 of bills (yeah), I only paid $2,000. While 2K is a lot, it is still less than the alternative.

    take care

    S

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    [Re: Insuranc paying for HCM specialist out-of-state?]

    Author: john jordan (---.public.svc.webtv.net)

    Date: 07-02-02 17:33

    hi karla, if my surgery had not been approved, my cost for the year would have been limited to the 2000 amount. there is a lifetime limit for out of network, self-referred. bc/bs explained this and i was relieved to know this before i had surgery approved in cleveland.also talk to peg judson at cleveland clinic, insurance expert. 1-800-223-2273 ext. 50430. she knows alot about insurance. lisa: yes, im getting ready for pre-op tests, appointments with dr. asher and dr. smedira on july 10-11, with surgery still on july 16th. regards to all, john
    NOTE: This is a post from the previous forum message board.
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