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 hope things pan out the way you would like very soon. Is Dr. Blackstone coming to your area now? I thought I read on here that she might start going there. I would be asking the insurance if they were going to pay for my transportation to the in-network provider? And also the lodgeing before and after the surgery? I will keep you in my thoughts and Prayers!! and Take Care, Wendy T.

Yes, Dr Blackstone has been coming out here every 3 to 4 months doing a support group and seminar on Fridays and Saturdays...I already told them during my medical review board hearing that I feel they should pay all the added expenses for my travel and hotels, but they said that is not part of their contract. NM bariatric program is not here any more either, so that only leaves one contract bariatric Dr. which is in Lubbock TX.