How do I get HMO referral to a breast surgeon?

madmot · October 2012

HMO is sending me to a general surgeon for lumpectomy. I've requested my HMO to approve an out of network breast surgeon, which they denied. Then, I found an out of network cancer center of excellence, which tells me they get lots of referrals from my HMO/insurance group, but, again they denied my referral and want me to go to a general surgeon. If my HMO doesn't have anyone who specializes in Breast Cancer, how can I get a referral? It seems ridiculous that you go to an ear,nose and throat doctor to have your tonsils out, so why wouldn't you go to someone who specializing in breast cancer for lumpectomy? Which may become MX, pending a second biopsy scheduled for next week.

itsjustme10 · October 2012

My only suggestion would be, if you know the breast surgeon, try to get the office to advocate with your insurance company on your behalf. Or for them to maybe write you a letter of medical necessity for you to try and advocate.

Otherwise, I'm not really sure if there's much you can do...your insurance policy is a contract between you and your insurance company, and you each bargained for something - you (or your employer) got lower premiums in exchange for more restrictive coverage. It's not like they're not letting you have the procedure done, just that they're requiring you to stay in-network, and while some surgeons unofficially specialize in breasts, there is no separate board certification for breast surgeons, so it's not like they left a category of medical professionals off your plan.

Good luck..hope you can find a way to work around your plan parameters. I wish I had a better solution for you, but other than having the doctor insist on medical necessity, there probably isn't too much that you can do or say to persuade your carrier to give you more expansive coverage than what your plan calls for.

Jomama2 · October 2012

My lumpectomy was done by a general/vascular surgeon whose sub-specialty was breast surgery. He did a good job. If you don't like the one they send you to, perhaps then you could argue to go out of network. For my hysterectomy, I had to switch "groups" entirely to see the doctor I interviewed and chose. It took 6 weeks, but worked out ok. Good luck!

How do I get HMO referral to a breast surgeon?

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