Health Insurance Issues

 

Judy Gordon’s Article on Insurance Approval Overseas

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Town looks overseas to curb health costs
Judy: “How I successfully lobbied for insurance policy changes to allow qualified surgery overseas.”

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Healthnet HMO Experience

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Unfortunately it is not good news if you have an HMO. In my experience, (I have Healthnet HMO) with an HMO you have to find a doctor within your network and also usually within a certain radius, mine was required to be within 50 miles of my home. The surgeon needs to be contracted with your insurance in order to qualify. When I was going through this process, it was prior to FDA approval so there were not many docs doing resurfacing let alone any in my area. They sent me to one at Stanford that claimed he did resurfacing but only did hemi-resurfacing.
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Healthnet Letter from Consulting Ortho

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This was the conulting Orthopedic Surgeons recommendation letter that pushed Healthnet to finally approve my request for hip resurfacing surgery with Dr. Amstutz.  Unfortunately, they sent the letter to me on December 1, the day I was in surgery with Dr. Bose in India.  They never reimbursed me for my surgery since they do not cover surgery overseas.
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Vicky’s Healthnet First Appeal Letter

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Note:  I copied this almost verbatim from Alan Ray, every single patient that I know of, that has used this letter has won their appeal.

Health Net
ATTN: Services Appeals and Grievances department
P.O. Box 10348
Van Nuys, CA 91410-0348

Dear Healthnet:

I have received a written notice, dated September 19, 2005, from Bay Valley Medical Group denying my initial request for pre-authorization for left hip surface arthroplasty. With this letter and attachments, the request is being re-submitted for further consideration as an appeal of the initial denial.

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Vicky’s Healthnet Second Appeal Letter

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Health Net
ATTN: Member Services Appeals and Grievances department
P.O. Box 10348
Van Nuys, CA 91410-0348

01/05/06

Dear Healthnet:

I have received your written letter dated December 1, 2005 denying my request for surgery in India but approving it with Dr. Amstutz of JRI. I would like to appeal this due to the fact that, as noted in the timeline below, your letter to me did not arrive until after my surgery date of December 1, 2005, which I had previously revealed to you.

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Medical Insurance Explained

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Research done by the AARP Legal Department

Q. What does HMO stand for?
A. This is actually a variation of the phrase, “HEY MOE.” Its roots go back to a concept pioneered by Moe of the Three Stooges, who discovered that a patient could be made to forget the pain in his foot if he was poked hard enough in the eye.

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 Posted by at 6:36 pm