Appealing/reversing a PPO health coverage decision

[fab13]

Hello. Years ago, my husband sustained a traumatic leg injury, requiring years of surgery (and, in order to save his leg and enable normal use, the implantation of a donor bone, screws, plates, and later, leg lengthening/stretching). He now has a 'low-grade' bone infection, at the previous surgery site, in his leg. The ortho surgeon, in our PPO network (we'll call him "Dr. P") referred us to one of the previous ortho surgeons (who did the initial leg-lengthening surgeries; we'll call him "Dr. V") b/c Dr. P said my husband's case is too intricate and difficult for him to help us. Health Alliance (our health insurance PPO provider) will only provide us with out-of-network coverage, should we continue treatment with Dr. V, stating we need to continue treatment with Dr. P (our in-network PPO). Dr. P has contacted the consulting physician for HA and explained why he can't continue treatment with my husband, but HA isn't budging and keeps demanding we seek treatment with Dr. P.

Basically, HA is demanding we get treatment from Dr. P only (in order to get in-network coverage), but Dr. P refuses to treat him (there are no other ortho surgeons, in our network).

My husband is scheduled for surgery, with Dr. V (the out-of-network surgeon) on Mon b/c the infection needs to be cleaned out, and we can't continue putting off the procedure.

Does anyone have any suggestions as to how we can fight HA and get my husband's surgery/treatment visits with Dr. V covered as in-network?

So angry; health insurance is such a scam :/

Thank you!

 

[ryanc111]

@fab13 Some or all of what follows may be useful, not necessarily to produce a resolution before Monday, but for doing this kind of battle with your insurer, which you probably already know can take many, many days:

1. apply occurrence dates to your already-pretty-detailed description of events
2. look up the names/email of your state-and-federal-level elected officials: (your state assemblyperson(s) & senators, or whatever they're called in your state) and your congressperson & federal Senators.You may also want to search for contact info for your state's department of insurance and/or department of health, to find out what department is responsible for handling health coverage appeals.
3. look up your health plan's appeals process -- on their website, or as an entry on your plan's Summary of Benefits and Coverage (SBC), which looks like this. Your plan MUST make an SBC available to you, so if you can't locate it, contact your insurer and/or your employer (if your coverage is employer-sponsored) and demand it.Prepare an appeal based on the information you find about the appeals process, which you may find even includes instructions about situations where an accelerated appeals path exists.
4. copy your elected representative(s) on the appeal you send to your insurer (or whatever entity governs your plan's appeals process). It helps to have the individuals/entities to whom you're appealing know you have people "in your corner" who have their own capacity to influence events and are interested in your appeal's outcome. Ideally, you can contact those representatives so they know first hand what your situation is. Pragmatically, by sending this info, they at least know you are a constituent with, potentially, an issue you might one day contact them about with a request for assistance.

I'm certain to have left off/not explained some useful stuff, so question away.

 

[fab13]

@ryanc111 Thank you so much! I def appreciate you! His surgery was just pushed back to Weds (12/14), so Dr. V could get auth from HA (for 'out-of-network' coverage) for the surgery, itself. Dr. P is still verbally trying to appeal their coverage decision (although he hasn't submitted a written appeal yet; he still thinks he has a better chance, speaking with the HA consulting-physician, personally, vs writing an appeal letter). In the meantime, I will begin searching for Dept of Ins/Dept of Health and elected official info, to CC on my own written appeal. I can't thank you enough for your detailed suggestions. We've always thought of ourselves as frugal and money savy, but this has taught us a great lesson (regarding the need for an emergency fund savings). I'm so angry at HA. Thanks again. I'll post an update, once I get any responses...hoping my experience (and your shared knowledge) can help someone else too. Even if I don't win, I want to put up a fight. Maybe I'll even get a lawyer??? Anyway, happy holidays, and thank you so much for your suggestions!

 

[inbetweendreams]

@fab13 File a single case agreement. Ask your doctor to write you a letter of medical necessity. Make a preservice appeal.

 

[fab13]

@inbetweendreams Thank you!

 

[fab13]

Update:
The in-network dr (Dr P) kept fighting against Health Alliance's decision, stating there were no in-network dr's who were capable of performing my husband's surgery. Health Alliance, however, refused to budge and kept trying to force Dr P (against his own, better judgement) to treat him. My husband ended up writing a letter (explaining the situation and how the lack of urgency/patient care was negatively impacting his health, and begging for assistance) to the head of our in-network hospital and the head of Health Alliance. I was confident he was wasting time and we'd have to get an attorney of something...but it worked! We were approved (as 'in-network') to have the surgery with Dr V (the 'out-of-network' dr). So far, so good. The surgery was performed last week, and my husband is now recovering. Haven't received any bills yet, but we have the approval in writing, so I'm trying to remain positive and hopeful that this whole insurance/billing/payment process goes smoothly. If all goes well and the bone infection is cured, my husband is hoping to go back to Dr V (in 4-6 months), to have the cement in his leg replaced with another bone graft...not looking forward to the prcoess of trying to get approved for in-network benefits again...but we'll cross that bridge when we have to. Thank you for all your suggestions. From his first 'my leg hurts' appointment to getting an in-network approval, it took about 90 days. I hope our experience (and everyone's suggestions) help other people, in the future. Don't give up!