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Fighting Managed Healthcare Decision?

Discussion in 'Other Off Topic Forum' started by PT 328, Feb 21, 2007.

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  1. PT 328

    PT 328 F1 Rookie
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    #1 PT 328, Feb 21, 2007
    My question is has anyone been successful in obtaining a referral to a healthcare provider outside their managed healthcare plan? ( Background ) My wife and her father have a rare genetic disorder called HHT. People with HHT can develop pulmonary arteriovenous malformations that if not treated can lead to strokes, brain abcess, and other complications. The good news is that these AVM's can be succesfully embolized. The bad news is my wife and her father are members of Kaiser Foundation Healthcare and have been for many years and they do not have the appropriately trained interventional radiologist to treat their condition. This condition should be treated very quickly to avoid the aforementioned complications so switching insurance at this time is not an option. There are 8 HHT centers in the US that specialize in this treatment and she requested that she have her treatment at the UCSD HHT center which has been denied by Kaiser. The scary part is that my father in law and wife's physicians have no clue about HHT and after their diagnosis through contrast CT scan, that we pushed for, have decided to just "watch" them. We have gone through the local and regional grievance committees without success. The next step is an independent medical review. Any thoughts or suggestions would be helpful. I apologize for the wordy post.

    Dan
     
  2. Under PSI

    Under PSI F1 Rookie

    May 13, 2005
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    Jim
    #2 Under PSI, Feb 21, 2007
    If I'm not mistaken, if you can show that it is a medically necessary procedure that cannot be performed by an in-network physician, then they are legally obligated to allow it. If there are in-network physicians and you would just prefer another one, then you may be out of luck. The same may be true if an alternative therapy to the one you are requesting is also available. Typically, you have to exhaust all possible in-network alternatives before an out of network referral will be approved.

    Good luck.
     
  3. Gran Drewismo

    Gran Drewismo F1 Rookie

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    Andrew
    #3 Gran Drewismo, Feb 21, 2007

    I believe that is the case, but I'm sure Kaiser will pay substantially less than they would with an in-network provider.


    I can find out about this at my work, since we're an outpatient radiology center.

    By chance, did they do a PET CT or just a standard CT? We offer PET, so if that's the case I should be able to get some clear answers.
     
  4. PT 328

    PT 328 F1 Rookie
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    #4 PT 328, Feb 21, 2007
    It was a CT with contrast that clearly showed 1 large PAVM and 2 smaller AVM's. The problem is that the top interventional radiologist at Kauser has only performed 10 embolizations of PAVM's. The HHT center at UCSD performs 100's per year. I am in the medical field and I had to laugh at the people that were on the commitees making the decision. None of them were medical professionals. My long term goal is to educate Kaiser about HHT and have their interventional radiologists receive additional training so that they may, in the future, be able to adequately treat this condition. Thanks for your assisitance.

    Dan
     
  5. jahock

    jahock Karting

    Nov 11, 2003
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    #5 jahock, Feb 22, 2007
    Dan-It's been a few years since I battled with managed care so things may have changed....but I agree if it is medically necessary/reasonable and there is no in-network provider, they should allow (and pay in-network benefits) on an out-of-network provider. So if there ARE in-network providers (no matter how inexperienced they are) they may not pay unless you can show that the out-network provider is doing a different type of treatment. The key is getting a provider on your side. Could you afford to pay for an out-network consult with your desired IR? We sometimes did individual contracts between our institution/physician and the insurance company. Of course, you will still have to convince your PCP that it needs to be treated now...but maybe the IR can help.


    Andrew-Are you using PET-CT for vascular conditions? That sounds interesting. We used CTA/MRA w/3D reconstructions for our vascular patients. It's really easy to mis-estimate the true diameter/length of an aneurysm or AVM with traditional CT.
     
  6. PT 328

    PT 328 F1 Rookie
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    #6 PT 328, Feb 22, 2007
    Robswife,

    Thanks for your advice. We plan on visiting the physician at the HHT center in San Diego for a consult then take it from there. It would be beneficial for both Kaiser as well as my wife if Kaiser would bring an outside expert in to advise them on the appropriate treatment of this condition.

    Dan
     

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