How to talk to an insurance company?

July 26, 2005 12:31 PM

My fiancé is having very rare hip surgery soon. Very few surgeons in the area perform it - she's found the one she wants - only problem is her insurance doesn't recognize him. What are some steps she can take to to help convince her insurance to give this guy the green light?

As I understand it, the insurance company will consider an outside doctor only if you convince them that you need this one and no other doctor will do. The doctor her insurance is recommending has only done this surgery 5 or so times. The doctor she wants has done it over a hundred, is "decorated" and generally sounds amazing. It's becoming a problem as she's trying to get prepared for the surgery, but the insurance company is starting to stiffen. She really needs this guy because it's complicated surgery and according to him, her hips are a unique case in themselves, putting her in an even smaller percentile.

posted by hellbient to Health & Fitness (10 answers total)

This is purely speculation, but would the doctor her insurance is recommending be willing to support her decision? I can't help but think one doctor saying 'No, that other guy is better for this' would hold more weight than the patient saying 'I'd rather see the other guy'.
posted by jacquilynne at 12:46 PM on July 26, 2005

One possible loophole: Is this doctor recognized by her insurance company for anything at all? I had a hand surgery done by a guy who, for whatever reason, my insurance had categorized as payable to do surgery in one hospital but not at the one we were going to use, and also apparently had him down as a children's surgeon but not one for adults. It may be a long shot, but all our guy had to do was file something with the insurance company and it was okay.
posted by Medieval Maven at 12:46 PM on July 26, 2005

Your best option is probably to just go out-of-network and pay the difference. Ouch. I would keep trying to get them to cover the more experienced surgeon, but if they have one in-network qualified (in their eyes) to perform the surgery I think it will be tough. The surgeon probably has a patient account representative or equivalent position in the office who can help you with insurance and payment questions.
posted by caddis at 1:11 PM on July 26, 2005

Good luck.

I tried this with my HMO, and it was no, no, no. You can appeal and then file a grievance, but it's unlikely that they will care.
posted by eas98 at 1:17 PM on July 26, 2005

Your profile says you're in Brooklyn; assuming your fiancé is also in NY state, then by law she can appeal (file a grievance) in accordance with her insurer's procedures. As to eas98's comment that the insurer won't care, I believe that is incorrect - if the appeal is upheld, the insurer must pay for the specialist that is wanted.

Personally, I think this is a strong case - for any type of surgery, it's much better to have someone who has done a lot of cases than someone who has done only a few. But I'm not a doctor (nor do I work for an insurance company).

It does sound like she needs to get a definite "no" (or "yes", although that sounds unlikely) from the insurance company, in writing, regarding the specialist she wants to use, so that she can start the grievance/appeals process.

She can also file a complaint with the Consumer Services Bureau of New York State (see link above), but I suspect there is more value in threatening to do so than actually doing this. But if the appeal/grievance is denied, it seems worthwhile to file a complaint simply to send a message to the company (and others buying insurance) about her unhappiness.
posted by WestCoaster at 1:43 PM on July 26, 2005

Talking to a lawyer who specializes in this area might also be helpful.
posted by winston at 4:18 PM on July 26, 2005

Assuming you have an HMO plan, which is what this sounds like, it will probably be a very tough sell. But without more information on your dealings with the insurance company so far, it's hard to tell what the best course of action would be. Who have you talked to at the insurer, and what have they told you so far?

(I ask because I used to work customer service at a health-insurance company, so working with cases like this was part of my job; if you'd rather not get into a lot of detail here in the public comments area I'll understand, and you should feel free to email me at the address in my profile)
posted by ubernostrum at 4:56 PM on July 26, 2005

If she can put off the surgery, there's always the chance that you could get the doctor into the network. I'd talk to the doctor and find out if he's willing to try that route. There's a good chance he's not covered under the network because he or his practice is unwilling to accept the discounts that are in the contract, but you never know. If he's willing and he's not part of a practice unwilling to work with the insurer in question, you could contact/get his billing people to contact the insurer.

Does your insurance have this doctor in network? Do you have an open enrollment in the near future? Does your plan allow domestic partners? Are you getting married soon?

If you are in a plan with an out of network component (a PPO or POS), I would second the recommendation above and just go to the surgeon you want and pay the deductible and coinsurance. It's very unlikely an appeal will have any affect, alas.
posted by MarkAnd at 4:58 PM on July 26, 2005

Response by poster: Fiance here, speaking in hellbient's place. Great suggestions, thank you all so much! I think now I just play the waiting game again. This surgeon IS apparently the only doctor in my region who performs the surgery (I've just confirmed that the ones they want me to go to do not). Only about five doctors in the U.S. perform this surgery and none take my insurance, according to my doctor's office. My only leg to stand on, so to speak, is that if it's medically nec. and no doctor in-network performs the surgery, the HMO will typically accept a nonparticipating provider. (With an HMO, there's no out-of-network benefit.)

So now I'm appealing again with the new info on the three dud docs and hoping they'll respond soon. Time is running out--it's nearly impossible with my job and risky to my hip to postpone the surgery--I have six weeks left to get approval. Much less, actually, since i must begin testings. Ball is back in insurance co.'s corner, so at this point I just wait, and hope.

WESTCOASTER: Technically, I'm no longer considered a NY resident (utilities and lease aren't in my name and I moved out of state for a while). Still, I will look into your suggestion. MarkAnd: The doc won't switch to take my insurance.
Thanks all!
posted by hellbient at 6:58 PM on July 26, 2005

Also, have your primary care Doctor write requesting the Doctor you want.
posted by DBAPaul at 8:50 AM on July 27, 2005