HMO's

crvzzz · July 2009

recently diagnosed with DCIS to inner upper right quadrant. .8cm very deep,next to chest wall. i am in HMO hell and am trying to get an experienced surgeon since the location of DCIS is unusual. does anyone have any tips on how to deal with HMO. they have one surgeon only available in my network. i hear he is horrible and am trying to get any other surgeon at that hospital which has an excellent reputation and a breast center. am i being unreasonable even though at 42 and otherwise healthy i made the mistake of opting for the HMO(won't happen again)? it has only been one week since Dx do have time to nit pick or should i go with the one dr and pin all my hopes on good plastic surgeon.

bluedasher · August 2009

Do you have other results from your biopsy yet? Grade of your tumor, HER2 and ER/PR (hormone) receptors? That can indicate how aggressive the cancer might be and give you an idea how risky it is to wait for treatment. You also could ask for a referral to a medical oncologist in your HMO to discuss how long you can safely delay surgery and what additional treatment you might need.

I'm in an HMO but its a large one with lots of doctors so I don't have any experience with getting approval to go to a doctor outside it.

Sue-61 · August 2009

I was a case manager (RN) for an huge insurance company and retired last yr. My best advice is to request a case manager by calling the member services phone number on your insurance card. Case managers certainly do NOT have magic wands, but in my experience, my medical director would let folks go out of network if there was good reason to do so. And I was "good with the words" and would need medical documentation as to WHY such a treatment would be approved. Good luck, Sue

crvzzz · August 2009

thank you all for your suggestions.for the record, i am in southern ca where there are some great surgeons but,i guess my network only contracts with some of the worst. i am waiting to hear from my pcp's office manager tomorrow who states that she is my best advocate for the right surgeon. i hope she is right. my next steps will be to see an oncologist and to call for a case manager's help. thank you again. i will keep all posted on my HMO wranglings. maybe,it will help someone else in my position and i hope that a long appeals process won't be necessary.

HMO's

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