Insurance Denied My Out-of-Network Referral

[mandksiders]

I tested gene positive for the gene that my mom (Midge) had before her transplant, but have not had any HCM symptoms and have been monitored reguarly for the condition. Now that we know I am gene positive, my family dr wanted to send me to Mayo to see Dr. Ommen because he is a specialist in HCM, and of course Mayo knows my family history. My health insurance is an in-network type insurance and of course we found out that Mayo isn't in our network. My dr filed an out-of-network referral claim because she wanted me to see a specialist due to the difficulty in diagnosing this condition and because of family history and the need to see a genetic person on this, none of which is available in my city. Well, the insurance denied the claim, saying that there is a cardiologist at the University of Iowa Hospital and Clinics who treats and diagnosis HCM and that I need to go there first because they are in-network.

I am so upset about this- first the man isn't a specialist and when I argued with the insurance company, they said he was. His name is Dr. Phillip Horwitz and nowhere in his information does it say he is a specialist in HCM, etc. I will of course, start there, do all the testing Mayo wanted to do and then wait until January when we can switch policies on our insurance and get up to Mayo.

Please don't get me wrong, the University of Iowa Hospital and Clinics are an amazing place to be, they are world-renowned in many things. I just am so disappointed that my freaking insurance company is doing this, I really wanted to go to a place that I KNOW has specialists and are tops in the HCM field and as far as I know, the U of I isn't, but Mayo is.

This has been a long week since I found out about the gene, am waiting for my boys echo results and dealing with this insurance, not to mention I am not sleeping, am stressed out and now I have a horrible toothache to top it off. Thanks for letting me get this off my chest. I just want the best care for myself and my boys from someplace I trust (Mayo), especially if we receive a diagnosis.
Thanks,
Kaye

[Reenie]

Kaye, I know how upset you must be about this. Is there any chance you can see the U of I doctor and then have him refer you to the Mayo since he isn't truly a specialist? I'm sure if you bring your mom with you to the visit, have him listen to both your story and hers, and talk to him, he will realize he just isn't equipped to handle this case. If worse comes to worst, I guess you'll have to wait until January, but I certainly hope that isn't the case. Please keep us updated.

[Cynaburst]

Kaye - Sorry to hear this news. Please do be careful though when switching insurance companies. Before you go to U. of Iowa, make sure that the new ins. co. isn't going to refuse to insure you or have a period of exclusion for a preexisting condition if you do get a diagnosis of HCM before applying.

[mandksiders]

Hi Reenie,
The nurse at our drs office did say once I see the cardiologist at the U that the cardiologist there can refer me to Mayo and because I had already seen the "specialist" (who really isn't one) they wanted me to, then insurance should approve that. I guess we will see.

Thanks!
Kaye

[mbcube]

I had problems with my HMO and the one thing I did was play their game. Go to their doctors. Do have their tests. Do bring copies (ugh!) of your records. But each time, tell them your story, bring your mom, explain the need to see a specialized expert in HCM and a HCM Clinic.

I did and had each of the 7 doctors write a letter to me and my insurance company. Eventually it will work. In the mean-time you'll know all you can about yourself and you may find a local doctor that you like.

Just keep it up, its not easy but you do what you have to do.

[mandksiders]

I won't be switching insurance companies, just to a new policy offered by the same company, they offer two each year through my husband's employer and you can pick which one you want. There is a pre-existing clause in each, but after a specific time they cover you and if you have been with the insurance company previously, they waive the pre-existing time clause even with the new policy. They won't deny you for a pre-existing condition(if I am reading it all correctly), which is good and I am hoping won't be an issue, just hoping that I will still be symptom free once the tests are done.

Thanks for the advice everyone! I will play the insurance game, see who they want and then go from there. My mom is coming to the appt with me and my husband, which should help, because she will know what to ask better than I will.

Thanks again!

[Reenie]

It sounds like your ducks are trying to get in a row for you. Best of luck!