I hope my post gives a path to navigate doctor offices and your HMO insurance to get coverage in other states where hip resurfacing is offered. As you may know HMO insurance contracts limit the territory to a local region of contracted doctors for your plan. In the case of my Blue Choice HMO I recognized no contract wording that gave direction for seeking coverage outside of the territory because the service wasn’t available in-network. Dr Thomas Gross said that because I tried in-network to get a resurfacing, and upon his determination that I was an excellent candidate, he could submit an application with my Maryland HMO for his services in South Carolina.
To me it made sense that an agreement outside of the Insurance contract was possible and binding, also made sense that if I couldn’t get an operation in my territory there should be some accommodation by the Insurer to provide the service elsewhere, and if I met resistance I had 2 agencies to appeal, the ACA Marketplace appeals board, and my state’s insurance administration.
I have an Affordable Care Act Plan (ACA) a Carefirst Blue Choice HMO. I called 3 doctors from google searches and the list of hip resurfacing doctors here at surfacehippy.info that were In-Network in Maryland and 3 Northern Virginia Counties that compose of my HMO territory and found that NONE were actively and regularly performing hip resurfacing. I am one not to let Doctors or any other profession bill for a job interview or what they call a consultation and I tell them that, someone at the office or the Practioner should be able to give you 10 minutes to answer questions. It usually works for me. Dr. C. Anderson Engh’s office in Virginia said he averaged 500, but would not clarify over what time period, further questioning revealed they had not done any in the past month or 3 months. A google search found Dr Marc W. Hungerford whose website describes all the benefits of a resurfacing over a total. When I called Hungerford’s office, they said they stopped doing them because Insurance didn’t want to pay.
I chose Dr Michael Jacobs who might have done one maybe in the last year, and had been awhile before that, but certainly was not regularly and actively performing hip resurfacings. He seemed to be my only choice in the hmo so I made an appointment with him. Upon examination he turned down for a hip resurfacing. So I made an appointment for a total hip replacement with Dr Jacobs and sent my information and xrays to Dr Thomas Gross in South Carolina.
A few weeks later Dr Gross called me and said I was a candidate! His office would help get Authorization, but I had to do some of the leg work too, and expect some resistance from the Insurer.
Here are some points I found important for getting out of state service , I did not take issue with Dr Jacobs that he turned me down. I needed him to decline me so I could use a surgeon who was actively and regularly and successfully performing hip resurfacing. I had a good idea that i was a good candidate because my femoral head was not crushed, and even if yours is crushed, mail your info to Dr Gross or your choice of surgeon who is actively doing resurfacings for their opinion. I tried 3 doctors who had past experience in hip resurfacings, I went through examination with one that indicated the possibility of a resurfacing and was turned down. I made appointment for total hip replacement surgery with the doctor and their hospital, so I have a proof that he wouldn’t give me a hip resurfacing. If I had it to do over, I would have asked Dr Jacobs for a document that says he is denying me or I am not a candidate for a hip resurfacing.
The billing clerks at Dr Gross’ office wanted me to do all the work. They hadn’t been successful getting Authorization from an out of state HMO in awhile. They directed me to Call Blue Cross “Member Services” number on insurance card 855-444-3121 and ask the first line of customer service “for approval on out of area service because I could not get a hip resurfacing in my hmo network of Maryland DC and Northern Virginia.”
I got lucky and was directed to Utilization Management (UM) Department 800-443-5434 who told me to have the Providing Doctors office (Dr Gross) call them to fill out a “Pre-Services Review Request for Authorization Form” Include the Doctors, Facilities and all to be reimbursed. and provide supporting documentation a case review write up that Dr Gross did stating “compelling reasons”; I was an excellent candidate, the conservative nature and benefits of a hip resurfacing compared to a total hip; the other advantages of a resurfaced hip that I could lead an active lifestyle and better sustain falls; the fact that I looked and was turned down by Dr Jacobs and to his knowledge he did not know of a surgeon in the Maryland area that was accomplished in this operation; therefore the patient has to go out of network to have this conservative hip replacement.
I’ll make a point when talking with the Insurer, don’t call this an “Appeal” or “Pre-Certification Authorization” those are different departments, the correct department for Carefirst was “Utilization Management” and it may be the same for other Blue Cross Blue Shields. Also, maybe in insurance terms an “Appeal” can happen after a claim is submitted but the claim is denied. The “Pre-Certification Authorization” was a different department, I don’t recall what they do.
2 weeks later, a day before covid shut down non emergency operations in Maryland, on March 22, 2020 I got verbal approval. So I don’t think coronavirus shut downs in Maryland had influenced a change in policy for the HMO contract. My next advice is to get it in writing. I later had to get a document “Notification of Authorization” from the UM Department so I wouldn’t have to sign a waiver of rights that would have had me on full responsibility of this $28,000 operation.
The “Notification of Authorization” stated “following services approved: CPT code 27130 and related covered services to be paid at the INN (In-Network) level of benefit.”
I had the operation July 15, according to my Explanation of Benefits, Carefirst has settled on 1 of 5 claims for this South Carolina surgery.
I am so glad I didn’t have to wait until open enrollment in December to pay up $600 more a month $7200/yr for a PPO policy in Maryland or move to South Carolina and get an ACA plan mid year there because of a life changing event.
I’ll give a thumbs up for Dr Gross for completing the application with compelling reasons of why I had to go out of state to get a hip resurfacing and that his practice was accomplished in the operation and he had data for better outcomes and lower prices.