Post-opp change in insurance

Hi,

I work for the state of MA and effective July 1st I will be under a new insurance plan which does not cover non-emergency services at certain hospitals, 1 of which is the hospital where I had the lap-band surgery last year.  I don't have any complications, but I do need to go for "maintence" visits for fills, consults, etc.

I have called my surgeon, who told me that he wanted to see me for a nominal fee (and therefore insurance wouldn't get billed and I would pay out of pocket), but that there were rules that would not allow for that.  It seemed like he really wanted to help, but couldn't.  Anyway, I called around to surgeons at two other local hospitals, but they said they won't take me because I didn't have the surgery with them, and it is their policy to not accept people who had surgeries in MA at other hospitals.

I have an appointment tomorrow with the program coordiantor at my current hospital to discuss what to do next.  I am nervous because I need to secure care...July 1 is just around the corner and I've been trying to figure this our since February! 

Has anyone else encountered this problem?  What did you do?

Thanks!

call your insurance company and tell them the problem you have switching doctors; i.e. that most surgeons won't touch another surgeon's patient. They could write you a waiver to see the doc when you need to. Sometimes they do this with certain specialists, or even for prescriptions. If they won't cooperate, call the insurance commissioner.  They can help negotiate with your insurance company.   They did once for me for a different issue. I didn't even need to file a formal claim...just their calling make Tufts have a different point of view of how they were processing a claim for me.
good luck.
Joan

joan,

thanks so much for your reply.  i did try calling harvard pilgrim and they still refused to cover the costs because the sugeon was at  a particular hospital that this plan absolutely will not cover unless its an emergency.  it doesnt matter that i have an established relationship.  (i think there are some politics going on behind the scenes..partners health is looked upon as a monopoly so insurance folks and most folks from community hospitals are VERY resistant to work with and/or support these surgeons/hospitals.)

i did have my meeting at my current hospital today...and the bariatric coordinator made a phone call for me and was able to convince the "new" surgeon to take me on.  it looks like i will be working with a new surgeon/program as of july 1.

i am fortunate to have coverage, though its with a surgeon i have yet to meet.  my biggest worry is that i could have encountered a serious concern/problem and have nowhere to turn.

thanks again joan, i appreciate the advice!

kristen

just as a side note this is not meant to knock harvard pilgrim at ALL.  they have been great all along...i think this was an employer's "change in coverage" issue more than anything...

i'm glad things are looking up in the insurance dept.    Don't worry about knocking insurance..they are a business.   I was greatful for Tufts to cover my revision, but had to call the insurance commision for assistance with my daughter's claim.... much less $$.   Go figure. But I am glad you won't be left without a doc.
joan