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HMO APPEAL

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jimmy r:
I have met with both Dr Mekena and Dr Barker. They have both expressed confidence in performing my surgery. Dr Mekena says he has done the second most acoustics in the country after Brackmann and has done about 30 recurences. Dr Barker also has a lot of experience . My concern is that they are recomending the retro approach. One says about 8 hours of surgery, the other about 10 to 12 hours. Brackmann is recomending the translab approach which would be 4 to 6 hours. It is my belief that I am debating on 2 top notch surgical teams. I am struggleing with 12 hours of surgery vs. 6 hours. This quite frankly scares me.  Even though I have been denied by HMO, I am acting like I have a choice and i am stressing over whether to file a second appeal or try the switching HMO's strategy ( an intersesting idea, thank you).
  I am in Maine, so Boston would cetainly be cheaper and more convient if I need follow up care. I know I have 2 good choices but I am stressing none the less. Thanks to everybody for your support. I am sorry to have missed the Boston brunch yesterday - I went to my daughters guitar recital.

tuckerro:
Jimmy R

In my mind, it all comes doewn to the matter of your comfort level.  If you are more comfortable with Brackmann, which I was, continue the fight.  I fought with my insurance for 6 + months after diagnosis to get with Brackmann.  If there is a will, there is a way.  If you feel comfortable with the Boston folks, then I saw go for it.  Best wishes in your decision.  Ron T.

jimmy r:
Ron T

Can you please give me more details about your insurance issues? Were you in an HMO, who was the company, did you use a lawyer, what swayed them?

Thanks

tuckerro:
Jimmy R.

I am an attorney.  So, while I thought of hiring my own attorney, after it was all said and done, I argued my own fate.  If it helps, I can forward you some of my letters, and appeals. 

MY HMO's fight, was the in plan, out of plan distinction.  There was a guy in plan that could do this, but only had 40 procedures under his belt.  Clearly a novice, as compared to Brackmann, who does hundreds of these per year, and thousands in his career.

I appealled to the end. The insurance doesn't think most people will.  My plan had the final appeal as a panel of people, unrelated to my insurance plan at all, in a different state.  The panel was a physician, nurse, and someone else in the medical field, totally unrelated to my insurance.  My  insurance had told me I could get microsurgery inplan from the novice, or go to Texas, and get Gamma Knife at a qaulifying or related hospital, with two other doctors.  I did my research on those fellows, which were nice, but inexperienced, and left me feeling panicked at the thought of them handling my procedure.

I argued like crazy, picked apart my patient's rights, and other documents for anything I could stick my foot on and argue about.  I argued that it had been my experience in dealing with Presbyterian, and through my entire appeal process and ordeal, that I have been specifically denied numerous rights granted to me as a member, while to my knowledge being in complete compliance with the payment of my premiums and all of my responsibilities under the Subscriber Agreement.  As a result of the interference with my rights, I have not been able to adequately defend myself nor my position in this appeal process, nor have I been provided with all of the information necessary to me in this appeal. 

I also argued that if a doctor didn't want to see me, they wouldn't force him to, and that as a patient, I should have the same choice.  I thought that was taken well by the panel.  I also argued that when comparing the track records of Brackmann versus the ones they wanted, the total experience, success rate, percentage of bad cases, etc. made it clear that there wasn't an in plan doctor of the magnitude that I could get out of plan, and that argument I think is the one that  swayed them to let me go out of plan. 

l am happy to discuss further with you.  I left out some of my arguments, but tried to throw the book at them, and lucky for me, they ducked, and I won!.   email me, because I can't always find time to check the forum for posts, and I check my email far more often.

RON.

tuckerro:
JimmyR.

How did it turn out?

ROn T.

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