My fight with Presbyterian Health Plan

Hello all, I am feeling pretty down today. I spoke with OPM and Mr Wilson is the person that is reviewing my case. He says that even though OPM hasn't responded that he will call them and find out their stand on why they won't let me go out of Network with Dr Blackstone. He basically said that most likely it is going to be denied. He said it didn't matter how many problems or deaths this other Dr has had out of Texas. I explained to him what my packet from my insurance says about competency and that if a contracted Dr. has less expertise or experience as a non contracted Dr, that I should be able to go to the Dr with more experience. Mr Wilson says that there are specific criteria that Presbyterian has to meet and if his office goes out side of that criteria, then OPM could get in trouble for it. Evidentially, OPM has a whole different set of Criteria than what my book from Presbyterian Health Plan shows. I asked him to at least read my packet before he makes a decision, it sounds like OPM really doesn't have a review board at all, and it seems that it is all just rubber stamped. I told Mr Wilson that this is not just black and white and there are more details to than just "does your insurance provide an In network Dr?" He didn't care about deaths or problems what so ever. On a brighter note, I met with Dr Blackstone again; she is such an awesome person. As I write this, I am in tears that I may be forced to go to a Dr I don't trust. My options as I see them at this point are go see Dr F in Lubbock for my consultative visit... (maybe I can ask him these straight forward questions about the deaths and problems his patients have had, if I make him mad enough, may he won't do my surgery and that gives me an option to go to Blackstone), or wait till open enrollment period and start this whole process over again. I don't like either option.

Hi, Richard, I'm sorry that the "powers that be" don't seem to be in the same solar system as us mere patients. I've gone and requested my PCP to request a referral to Dr. Blackstone, that way, even if she comes on network after the first of the year, I've started the process. If they don't take her on, I'm not going to have the surgery done by Dr. F. My life, for now, is worth more than the chance that I feel I'd have to take. You're not alone, and you've got a young family to think about, so try not to second guess your decisions. Jean

Hi Richard! I'm sorry you're having such a terrible time with the insurer's. It's so stressful to hit road block after road block!! Hang in there, I'll keep you in my prayers. Cindy

Richard, you hang in there, I feel so bad for you and understand how you feel. I wanted this surgery so bad and wanted a certain Doctor but I ended up going to the Mayo clinic and I am so glad I did. I will try and go to the meeting next time 09/01/04, and maybe we can talk. Give me a call anytime.

Richard, This may be a dumb question, but will your insurance at least pay SOME of the fee for out of network doctors? My insurance paid 70% for my surgeon, and I will be billed for the 30%. The hospital I used WAS an in network hospital, so I only had to pay $500 co-pay. The doctors office is going to work out some financing with 0%. I'm sure that Dr. Blackstone will work it out with you, especially since you want her to do the surgery so badly. I guess what I'm saying, is to NOT let ANYONE, or ANYTHING 'force' you to do something that you do not feel comfortable with. You may not have insurance pay the entire thing, but even out of network they have to pay something.....and who knows, maybe soon she will be IN-network and all will be well. Enjoy that little baby of yours..........and remember that all things happen for GOOD. Praying for you, and your family, Beckey

Well, first off, I wish you luck in going to whomever it is that you want to.....personal preference is powerful! Secondly, I am planning to have my surgery done by Dr Frezza. It sounds like you have heard rumors--but nothing substantial. During the consult, Dr Frezza is very upfront and blunt about issues his patients have had in the past. He's a challenging doctor in what he requires from his patients before he will operate (in terms of commitment and procedures). I have spoken to several of his patients personally and have not heard anything negative until I just read your post. Since I am not going into this blind folded, I would be very interested in hearing the rest of the story so to speak but from what I know, I have no reason to doubt my confidence in Frezza--but my ears are open Best to you! am

I wanted to let you know I just finished reading your profile! WOW! What a long, tortured battle you have fought. Its almost like the battle became the focus and not why you were battling at times. That is a shame. If they had just honored you in the beginning image how far you would be at this time! And how much money they would have saved on lawyers, etc. ARGH! You seem patient so I will be irritated for you today, lol. Anyway, too bad you did not come to Dr Frezza's yesterday, I was there and we could have met since we live in the same community! Anyway, if you have any questions regarding my experience with Dr Frezza, I am available to you. Much luck! am

I meet with Dr Frezza on the 15th of September. I still haven't heard anything from OPM. Thanks for the fax...