Do PPOs get more approvals than HMOs?

I currently have United Health Care 'HMO-like" plan with copays, no max, etc.  I was wondering if approvals are easier to get on a PPO vs the HMO?  I am looking for Pannus removal and/or abdominoplasty.  Any advise is helpful, especially if you had/have UHC insurance.  Thanks!

I tend to think this is the case.  HMOs have their fans but I voluntarily pay much, much more for good PPO coverage.

I don't know the answer to your question but I have Blue Cross Blue Shield PPO and I was approved for my tummy tuck. 

I wish you the best of luck.

Sherline

Unfortunately it tends to seem that way but that's because sometimes the gate keepers of the medical group are what hold up the approvals - not the actual insurance company itself.

It also tends to appear that way since people with PPO may be more inclined to have these types of surgery since they can go straight to the surgeon of choice instead of having to get approval from their primary care physican to see the surgeon.  And only then sometimes you are limited to the surgeon you may want to see because perhaps they aren't in your medical group, etc.

Your HMO-Like plan...I assume it has out-of-network benefits and you don't need to designate a primary care physician and/or can self-refer to specialists?

Good luck with everything! :)

Cheers!

Tisha aka your resident health care insurance industry broker/administrator/nerd. lol

Thanks for the response.  Yes, Tisha.  I do not need referrals, and most likely the surgeon would probably be out of network.  I spoke to my doc and she says for me to gather the pics, and she has records of rashes/meds for it as well as the couple of UTI's that I have had over just the past 3-4 mos, and the MANY back probs/surgeries I've had.  She is more than willing to help me out on the paperwork but she is my primary doc.  Should I be seeing the surgeon and having him write this up or do you think I should just stick with my primary for the pre-determination the ins is requesting?

When I met with the PS, he stated that they actually have better luck with the insurance companies it they just submit the paperwork to them AFTER the TT is all done, and not to submit a pre-auth form.  This part doesn't make sense to me because if he is already paid out of pocket by ME, what incentive does he have to go to bat for me once he has already been paid??? That just seems strange to me. What do you think?

Thanks again soooo much!

 If I had met with a PS who wanted to submit to the insurance after the procedure was done I would turn around and find another PS.

Most procedures of this nature require pre-approval/pre-authorization...not "have it done and then submit and cross fingers."  That's odd that he would say that and imply that he has more success with it?

I agree that once you've paid out of pocket for something he doesn't have a lot of incentive to submit to the insurance at that point...especially since you would be owed some sort of a refund after the fact.  If he's out-of-network then he isn't able to give you a network discount, however, he also can charge whatever he wants and once the insurance pays the Usual and Customary for that procedure in that area, then he can charge you whatever he wants for anything over that.

Do you have any access to surgeons in your area that are in-network?  If not, are there any other surgeons you can consult with that are out-of-network, however, willing to submit to insurance for pre-auth?

I'm sure you already have this information, but I pulled up the criteria for a panniculectomy/abdominalplasty from our broker site through UHC and here is the information I was able to get:

Must meet all of the following criteria:
- Documented inability to maintain hygiene of lower abdominal skin folds and genital area with conservative treatment
- Medical record documentation that the pannus causes chronic intertrigo or skin maceration that consistently recurs over 3 months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 3 months
- Pannus hangs below the level of the pubis
- Documented weight loss as a part of conservative means of controlling symptoms. Weight stable for minimum of 3 months

Documentation required:
- Letter of Medical Necessity from physician
- significant functional anatomic impairment
- photos that illustrate skin changes due to pannus
- current weight and height of patient
- medical records outlining failed treatment attempts.


Panniculectomy and Abdominoplasty do require pre-authorization from UHC so I would be hesitant for you to have the surgery and then submit the claim for reimbursement.

Cheers!
Tisha :)