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my HMO says no go
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04-09-2001, 11:33 AM
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my HMO says no go
My doctors office just called and said that my surgery pre-authorization has been denied from my HMO. They said that this is a last option and other forms need to be taken. So, I have to stay in pain, take drugs that don't agree with me, have a coposcopy, another sonogram and then if it still shows problems then we will try again for another auth. Meanwhile I am going to continue to be in pain and bleed like crazy for awhile.
I'm at wits ends. Anyone else had this problem with their insurance company dening the surgery?
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04-09-2001, 11:37 AM
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Posts: 23
Hysterectomy: April 6th, 2001
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Insurance Denied
Hi Sunshine,
No, I did not have any problems with insurance denying my surgery. However, I do medical billing, and appeals for a living. You need to get a little involved with your insurance to help out your physician. I would be more than happy to help you with what knowledge I have if you would like to email me at: DeservedMyCrown@aol.com
Hang in there..............Sara
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04-09-2001, 11:57 AM
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Posts: 519
Hysterectomy: April 10th, 2001
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my HMO says no go
Mine went right through, but I had a 6 year history (at least) of problems. I'd been through Depo-Provera, 2 Laps, Lupron, many different BC Pills, etc.
They want to justify the expense. I got email the other day from a girl whose insurance denied the Lupron the Dr wanted because they said "You'll end up with a hyster pretty soon, anyway." Well, with endo, that is not always a sure thing. There are plenty of people that the drugs help. And the hyster will cost what $5000 or more?
I would say, get all your records together, showing all the years you have had problems,including with other Docs and other insurance. Then begin to wage war!!! It is ultimately the decision of you and your Doc. If you need to, contact the insurance regulator in your state about being denied appropriate treatment.
Good luck!
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04-09-2001, 12:04 PM
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You could move
You could move to Canada and have your surgery covered by insurance in three months.
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04-09-2001, 01:40 PM
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Posts: 277
Hysterectomy: February 3rd, 2001
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my HMO says no go
I too was afraid of my HMO regecting my surgery or even my original primary physician regecting the thought. I took in the MATH!! that horsewoman suggested.
Ask your mother how old she was when she FINISHED MENOPAUSE, subtract your age and that is how many years until you are finished with menopause.
Then take the number of days you suffer each month, multiply by 12 (#of mos a yr) then multiply that total by the number of years until you finish menopause.
I did that math, my mom didn't finish menopause until she was 58 yrs old. At the time that was 22 yrs for me. I bled 10 days out of the month, but suffered with PMS, pelvic pain, etc for the 7 days prior. Anyway it figured out to be 4488 days of suffering until I was finished!
That was unacceptable. I took all of this information to my ob/gyn and I am assuming that he submitted it with the surgery approval request as I was approved within 24 hours. The only other test that I had to have was an endometrial biopsy to rule out uterine cancer. From my first visit with my ob/gyn, until my surgery it was less than 2 months!
I agree with Sara and Barb, get your records together, do the math, take charge of your health. The HMO only sees the bottom line, they hope they will make it so hard to get approved that you will give up. DON'T GIVE UP!
hope this helps
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04-09-2001, 07:02 PM
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my HMO says no go
Thanks for your advice. I have had 7 laps for endo, I was averaging about a lap every year in a hlaf up until I finally got pregnant with my first child.
I am do back in his office in two weeks, then we are going to go full force. I am tired of all this pain.
I will let you know how I make out. It's nerve racking when the insurance companies can try to control your health.
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04-09-2001, 07:22 PM
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Posts: 66
Hysterectomy: April 12th, 1992
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Wow!
I havent even given a thought as to whether my insurance would approve or deny my surgery! Mine was quite sudden and my doctors office handled all that! I never even had to deal with the insurance company at all!
I guess all things considered I am very fortunate to have the coverage I have. I was reading a post yesterday about one princess that was literally kicked out of the castle by her insurance company!
After reading about this princess it did make me curious about my particular insurance company so I checked with our group insurance agent today about the time allowed for my kind of surgery (TAH/BSO) he said that have set 3- 7 days for that type but if more is needed all the doctor has to do is submit a reason.
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04-09-2001, 11:18 PM
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Posts: 229
Hysterectomy: January 15th, 1992
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There are several things you can do......
First, you can always proceed with the surgery and appeal the claims after the fact--I don't recommend this unless absolutely necessary as the insurer will find out you were informed of the denial and opted to proceed anyway so you run the risk of being $ responsible. Still, its an option.
Second, get on the phone with your state's Dept of Managed Health Care--this is the REgulatory body that controls your insurer's operating license. Request Expedited assistance with the denial you have been informed about. Be clear in stating why you think its inappropriate to be subjected to further conservative measures when your specialist thinks surgery is your best option. If you can get something in writing signed by your GYN that would help greatly.
Third, call your insurance company's Customer Service number (its usually on your insurance card) and state you are requesting an Expedited appeal in response to the denial you were just informed about. ID you are in a LOT of pain and something has to be done. Expedited appeal processing occurs over a 72 hr time period from start to finish. This puts the burden back on the entity that actually issued the denial. Directly ask to see the criteria used in making the denial decision in your case.
An even better option is to have your GYN office request the Expedited appeal on your behalf directly with the insurer.
Don't give up-FIGHT!!
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