HRA and Self Insured Companies

[Scottmwill]

I am a former employee of HCA in Denver. HCA is self insured and the TPA is Cigna. HCA requires you to get a procedure at one of their hospitals if you use their benefits for business reasons. The surgeon they want me to use is the only surgeon in all 5 of their Denver area hospitals and she has done 120 HRAs and does not think she can successfully complete an HRA because I have FAI and all but assures me I will come out of the surgery with a Total Hip.  The surgeon I want to use has done more than 1000 HRAs and is confident he can complete an HRA for me, but he doesn't operate at an HCA hospital. Since he also backs up his HRAs with a Total Hip if necessary Cigna on behalf of HCA says there is no difference in surgeons and I must get the surgery at the HCA hospital in Denver (the "total hip" doctor).

HCA is  the final level of appeal. I have had my preferred surgeon conduct a peer to peer with a Dr Rossi and my appeal has gone all the way to the "national" Cigna appeal process. They have upheld this Dr Rossi's denial. They haven't yet told me if there are an ortho doctors involved in any of these appeals.   HCA says that will not allow an appeal until I have had the surgery and commited to paying 75% of the cost, then and only then will they review my appeal. A good business model for them but obviously not for me.

Cigna says an external Independent Review is available (by a vendor they pay) however I cannot tell from the benefit language if utilize this option if civil action is still available if things go south. But it does seem likely that if I don't follow the appeals process no court will touch it.

1) Anyone had any success dealing with self insured companies?
2) Anyone know if using an external Independent Review essentially waives your right for civil action?
3) ANY other thoughts or advice?

[3Chords]

Scott - not sure if any of the following is relevant, but it may be. My son needed a cochlear implant and my self-insured employer was not supportive at first. Here's what ended up to be successful...

 First, we sent a certified letter to our benefits office, indicating that we'd engaged an attorney. Second, we provided written justification regarding his (my son's) specific procedure, including long-term benefits and associated risks. For a THA, this should be pretty easy to do. You should be able to find numerous case studies, so that the procedure will be easily confirmed as medically necessary and not experimental.

 Our office told me that they were sending my documents to an external review agency. I assume that you could request that external review without them offering it. At no time did they indicate that further legal action would be restricted by this procedure. The external review agency reviewed and returned a "positive" decision".

 We then went through the process to get the implant manufacturer recognized as in-network, since there aren't any of these providers locally. That gave us basically in-network deductibles and the like. Surgeons and specialists were already in-network...

 Once these steps were finalized and documented, we were able to get his surgery scheduled.

 One of the most critical steps was finding a contact in our benefits office, who handled everything. This person is now a valuable contact who's asked me for information about other people here who are looking at implants. She's a "special case coordinator" or something like that.

 Our insurance agency is Highmark Blue Shield, if that makes any difference. Ours was a "procedure" question, yours appears to be a "not qualified provider" issue. I'm not sure how that plays in this situation.

Best,

Jim

[Scottmwill]

Thanks Jim.  Any information is useful.