Pacificare HMO Question

[wayne-0]

I am just starting the process of getting approval for bi-lateral hip resurfacing from pacificare HMO.The doctor I want to do the surgery is Dr. Scott Ball out of UCSD.My question is; He is out of my medical group and I was wondering if anybody out there got approved through pacificare hmo to go outside of their medical group to have this surgery? Also, if you did get approved was easy or did you have to fight, please give details. Thanks.

[Pat Walter]

Hi Wayne

Dr. Ball has many happy hip resurfacing patients.  If you can't get your insurance to cover him, you are lucky that out in CA there are many expereinced hip resurfacing surgeons. 

You might want to check my doctors list to see if any of the experienced surgeons are on your insurance companies list  http://www.surfacehippy.info/listofdoctors.php#California_

A lot of people have had to fight with their insurance companies to get a hip resurfacing, etc.  I have a group of sucessful letters  here   http://www.surfacehippy.info/insuranceappealinfo.php

Unfortunately, I don't have health insurance, so I can't help you with any other personal info.

Good Luck.

Pat

[wayne-0]

Hi Pat,

Thanks so much for all your hard work and dedication. I've learned so much from your website and because of that I feel real comfortable about making decisions regarding my bi-lateral hip resurfacing surgery that I'm waiting for. There is no other site that even comes close to providing the info you have put together. Thanks again.

                                                       Wayne

[Pat Walter]

Hi Wayne

I am glad Surface Hippy has been a help to you.

I hope after your bilat surgery you will post your story which will help others.  Most of the website has been built from people sharing stories and doctors sharing information to help other people.

I spend a lot of time posting things on the website - but without the patients and doctors, I would not have much to post.

Good Luck.

Pat

[wayne-0]

Here is whats happening,
It seems as my medical group(Monarch) is trying to wash their hands of making  a decision for allowing me to go outside my medical group to have this surgery. The sticking point is that in my medical group there is one doctor that does hip resurfacing and they would prefer me to have him do the surgery.This doctor has only done 4 resurfacings and told me in my consult with him that he is not really convinced that resurfacing surgery is very successful.He told me he likes to have at least a 20 year study to feel like he has the necessary info to make concrete decisions on success rates. On that note, I appealed to Pacific Care on the 19th of August to have Dr. Ball do my surgery. My wife and I spent a considerable amount of time making phone calls to both Monarch and Pacific Care for the next 3 days explaining the whole situation and Pacific Care has now ordered an appeal to review all info pertaining to this case.A decision will be made in the next 15-30 days if they are going to allow me to go outside my medical group and let Dr. Ball do this surgery.I will keep you all posted as to what happens. 
                                            Wayne

One more note, any one trying to get approved for surgery make a list of all people you talked to,name,time, date,any info they tell you about your case, this is a little fire power when it comes time to appeal any decisions.

[wayne-0]

Hey Hippies,
Great news,  surgery approved with  Dr. Ball who is outside of my medical group! For those of you who have had to deal with HMO you know what a miracle that is. First off, to all who posted appeal letters and info thank you, thank you ,thank you. All of your postings were instrumental in my dealings with my insurance company. I will forever be grateful that you took the time to post your letters, successes and failures. Before this ordeal started I did not know I would have to go thru the biggest fight of my life to get an approval, but that is exactly what it became. My process was denied and stalled many times over. First wih the medical group, then insurance company, then appeals after appeals. I was told my last hope was to go to the department of managed health care (California state run entity that reviews HMO concerns) IMR unit  www.hmohelp.ca.gov/.   Fourtunately, I never had to get that far. Here is what helped my case, I filed a greivence case against my medical group, then Pacificare(insurance company got involved with that). I contacted United Health Care (parent company of pacific care) about the greviences and they got involved. There is a department called Quality Intervention Services Department that got involved. Go to this department if you need help with any problems, they were wonderful and really helped out. Filing a grievence in my case turned out to be a very powerful ally. Be very specific as to what you believe are the wrongs and all facts. I could go on forever about the specifics but this is long enough already. The good news is sometime early November will be surgery date. I'll let you know when I find out.
                                                      Wayne-0

[Pat Walter]

Wayne

That is great news.   Your effort was worth while.

I wish you the best of luck.

Pat