GIST Support WikiAfter dealing with insurance companies as my job for many years I have a few suggestions when an insurer turns you down for a procedure or treatment or medicine.
First, YOU must be your best advocate. Do not take NO for an answer until exhausting all of your appeal rights. However:
I always recommend patients getting a specific person at their insurance company to be their "Case Manager". This is the person that should be or become familiar with you and you history, so when things need to be done, they have access to your files and things can be sent directly to them.
Going out of network is more expensive for the insurance carrier. Those doctors do not have pricing agreements with the carrier. A doctor might be participating with a carrier for some plans, but not others.
If you are told that you must stay in network: Ask your carrier for a list of the doctors that "supposedly" can do "the same thing", that are participating within your plan. Call those doctors offices and check it out. Ask for the person (surgical nurse, surgical coordinator or whomever) at EACH doctor's office that can tell you if they do the 'what ever" procedure, how many they have done and if they have GIST patients. It is possible that an insurance company "thinks" that they have doctors that are qualified to do the "what ever" procedure, but the doctor's office may tell you that they do NOT do it. Document the day, date, and whom at each office you spoke to and be able to present your findings to your insurance company.
Get documentation from your own doctor as to WHY he/she/they feel that "Dr.X" is the best person to do this type of procedure. Also get a letter from Dr. X, as to why HE/SHE feels that you need to have the procedure done by him/her, how many they have done, familiar with GIST, etc. There is a good chance that they have had to do this for other patients also.
It also can not hurt to ask Dr. X "personally", if they would be willing to accept what your insurance company would pay, as payment in full or along with your normal in network copay. It NEVER hurts to ask. The doctor can override their normal fee schedule, in many cases. This is especially true if the doctor is in a solo or small practice. Even larger practices have "special circumstances", and the insurance coordinator can also discuss a particular case if there is an operating committee within the practice. This might help in the case of out of network, where the insurance carrier might be willing to pay the doctor what they would pay if the doctor was participating with them.
Once you have a case manager or appeals manager, have your doctors send or fax information directly to that person and then follow up with a call to make sure that the information has been received. Get copies for yourself and keep them in your files for future reference. Then keep in contact with that person to see where your case stands.
It is easy for a person at an insurance carrier to turn down someone who is NOT standing in front of them!!! I have even heard that processors were instructed to have procedures turned down due to costs until they were inundated with paperwork showing "MEDICAL NECESSITY".
Each doctor has a person in their office(like me), whose job it is to precert procedures and deal with insurance carriers. Many times they have their own contacts within the various insurance companies and the squeaky wheel gets the grease. Many times, I had to go to bat for a patient to get surgeries approved for many reasons. I took it as a personal challenge to get our patients the medical care that they needed. ASK for that person at your own doctor's office and see if they can help.
If your insurance is private, call your agent and get them to speak to their contact at your carrier. If it is employer sponsored, call the HR person or the person who is the liason at your employer's to contact their agent. After all, someone pays the bills!! The insurance company has a responsibility to the person who sends them a monthly check.