With you all the way Bosda. The words for HMOs cannot be used in this board.
Without knowing which HMO you have, I’ll try to suggest some approaches I’ve used. First, if you are having chest pains, you can and should go to the ER; as far as I know the HMO has to cover the ER treatment when it is for a potentially life-threatening condition. Many have very tricky regs as to what happens next. For most, you have to notify them within some short period of time, like 24 hours after that. If possible, try to go to a hospital that is in the HMO network. If you get admitted, you probably will have to jump through some more hoops to get the hospital stay covered after the first day.
ER care is relatively expensive; if you are making a trip per week for your recurring chest pain, they might decide it’s cheaper to let you get real treatment. Not that I’m suggesting in any way that you should commit insurance fraud or feign symptoms that don’t exist.
Now, if you’re talking about appeals, couple of things. Someone I knew who worked for an insurance company told me that the first reaction of all of them is to deny coverage in the hope that you will go away, even if they know they are wrong. You may have to go through their entire appeal process, which they will draw out as long as possible. If they eventually end up paying for it, they will have kept their money all that time, with no penalty. As long as you don’t delay necessary treatment, there is no down side to doing the appeal except the annoyance.
Be sure your letter is sent with a return receipt. These things tend to get “lost” otherwise. For any phone calls, keep a careful record of the date, time, the name of the person you talk with and exactly what you were told. Repeat the instructions to be sure you have it right. If it’s legal to do so where you are, record the conversation. If at all possible get the first AND last name of everyone you speak with. Ask them exactly what they want – is it just a letter outlining your case, or is it a form to fill out? Remember, too, that whoever you’re talking to on the phone is probably just a clerk whose job it is to answer the phone and say “no.” If you can’t get a straight answer, ask politely to speak with a supervisor. Rinse, repeat as necessary.
Depending on what the cost of the rest of the eval is, and what your financial situation is, you could pay the rest out of your own pocket to avoid delay, and also appeal their decision at the same time. If you win, they will have to reimburse you.
You could also ask the HMO for the name of a cardiologist (or primary care doctor, if they require you to see one of those first) who IS in their network. Get all your test data from the first doctor. I believe they have to give you that. If possible, bring the exact lab report, not just the summary conclusions, to the new doctor.
If/When you go through the HMO appeal process, be sure to lay out the facts as precisely, specifically and as concisely as you can. If you have or can get anything in writing from a doctor outlining the potential seriousness of the situation and why it must be followed through as soon as possible, do so. Don’t become abusive, rude or emotional (not that I’m suggesting you would).
You can also ask the HMO for a copy of whatever their policies are regarding in- and out-of-network care, and for a copy of the policy or regulation that about dealing with a doctor who leaves the network in the midst of treatment. Assuming you got the coverage through work, the HR person in your company may be able to help you out with more information about what is covered and what is not.
Another possibility is to ask your current doctor or his stand-in if they have a recommendation for another doctor that is in your plan. They should as professionals have no problem with that, especially since they will be losing you as a patient anyway.
Bottom line: Don’t mess around with chest pain. You could have inherited your father’s condition. You could also have a partially blocked coronary artery that is just waiting to close off the rest of the blood supply to your heart. Any doctor or ER will tell you that they would 100 times rather have a person with chest pain come in unnecessarily to be diagnosed with indigestion than to have him come in on a gurney too late for them to do anything. Doctors really hate that. On the other hand, the insurance company doesn’t mind a bit, since then they will never have to pay any of your bills again.
