I need help fighting my insurance!

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anna42
anna42 Member Posts: 2
edited July 2015 in Just Diagnosed

I was diagnosed 2 weeks ago following a lumpectomy with IDC. My Dr is recommending mastectomy. My insurance only has one provider in my network and he has horrible reviews online. I had the DR I wanted to use submit a request for an exception it was denied even though they have privledges at my hospitaland offered to do the surgery for any fee BCBS would pay. Has anyone had any luck fighting for options of surgeons? It seems so unfair to only have one option when my city has some of the best plastics in the world! Any advice???

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  • Moderators
    Moderators Member Posts: 25,912
    edited July 2015

    Dear Anna, we're sorry for what brings you here, but wanted to say welcome to this caring and supportive community!

    Which city-area do you live in? That may be helpful for other members in order to give you some feedback on surgeons and different options. Anyway, if you want you can take a look at the article Managing Your Health Insurance from our main site, for some tips that can help you work with your insurance company to make sure you receive all the benefits to which you're entitled.

    Hope this helps!

    The Mods

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  • Sue-61
    Sue-61 Member Posts: 599
    edited July 2015

    Anna, I think you can apply for a second level appeal on this denial. Did your insurance company offer you this option? I am assuming you have a HMO and have to use in network benefits. Do you have the option to go out of network? Many times going out of network has higher copays but if this is something you can do, you could try to negotiate with the doctor who you want to see. Again, I also wish I knew where you lived. I can understand your frustration! Keep us posted, Sue

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  • anna42
    anna42 Member Posts: 2
    edited July 2015

    Sue, I live in Phoenix. I have an HMO plan Network Select Blue Cross Blue Sheild AZ. I don't have any out of network rights unfortunately. I just feel like it is really crazy that I have only one choice of DR! Especially since that one DR has such a bad reputation...I feel scared and frustrated.

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  • gale1525
    gale1525 Member Posts: 232
    edited July 2015

    Maybe you could switch groups to get a doctor you would like better. That happened to me also I refused to use the doctor they wanted me to use. Phoenix is a big city and you should have a fairly good choice of group's. Maybe check groups associated with St Joseph's Hospital & Medical Center.

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  • MelissaDallas
    MelissaDallas Member Posts: 7,268
    edited July 2015

    If she has an ACA policy she may be right. I'm in a huge city & only have a couple of doctors that are in their so-called "network"

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  • BrooksideVT
    BrooksideVT Member Posts: 2,211
    edited July 2015

    Anna, do keep in mind that anyone can post anything on those sites, and that if the doc you are researching is a plastic surgeon (couldn't quite figure out whether you were writing about a breast surgeon or a plastics guy), lots of women have unrealistic expectations. Also, those who have amazing results rarely post. To really determine his qualifications, check where he did his training and also at which hospital/s he has privileges now, and how long he has been there. Hospitals have regular meetings where they look at the poor outcomes and examine how to prevent them in the future. Bad docs don't get to hang around long. Blue Cross/Blue Shield also has to have high standards. If you are still uncomfortable when you meet with him, feel free to bring along the "ratings" when you see him and ask away. He will not be able to address specific cases, of course, but he can address his personal overall results. Once you have met with him, chances are your confidence level will soar.

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  • MelissaDallas
    MelissaDallas Member Posts: 7,268
    edited July 2015

    I agree with Brookside

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  • Sue-61
    Sue-61 Member Posts: 599
    edited July 2015

    Brookside is correct. Here is hopefully a link where you can look up actual info about doctors and it includes lawsuits and such, but mostly where they trained. This might be helpful is allaying your fears, Anna.

    http://docfinder.docboard.org/

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  • BrooksideVT
    BrooksideVT Member Posts: 2,211
    edited July 2015

    I'll add that I would totally panic if I felt forced to use a doctor I didn't trust, and that it is absolutely appropriate for you to be frightened, enraged, and any other way you might be feeling. I would think your insurer would be required to have more than one option up their sleeve--what if their one-and-only goes on vacation? Someone must cover his patients. Who is that, and why can't you use him or her?

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  • MelissaDallas
    MelissaDallas Member Posts: 7,268
    edited July 2015

    Obamacare plans are truly horrendous

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  • Kicks
    Kicks Member Posts: 4,131
    edited July 2015

    I disagree with the 'idea' that only those who have had bad experiences ever post. I have posted often (not just 'here') about the good/great experiences I've had. I'm not the only one who has posted positively in many places. It seems though that basically no one ever reads positive experiences (or believes they exist) but prefer to dwell in the negative.

    I know nothing about Obama Care or dealing with insurances - my fantastic care was/is through VA. I was immediately outsourced to private care for all my TXs and surgery.

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  • Moderators
    Moderators Member Posts: 25,912
    edited July 2015

    Dear anna42, We are just checking back in to see how you are doing with all of this We hope that the support of our members has been helpful. The Mods

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