Question:
HELP!!! MY COMPANY HAS HMO ONLY AND DOES NOT OFFER

I was all set to change my insurance in November, and then I found out my company only carries HMO my doctors out of network what do I do? I am a single mother and I need this surgery were do I go from here?.    — D. WILLIAMS (posted on July 18, 2003)

July 18, 2003
I would get my PCP to refer me to a surgeon that does the surgery. Get him to request the surgery through your HMO or PCP. If they refuse, which they probably will, write an appeal letter. Give all the info you can about the surgery and why you need it. Keep appealing. Check out the area on this site about appeals.
   — Yvonne G.

July 18, 2003
I had a similar problem... my HMO didn't refer to the program at their own hospital, but one at the nearby university, and that's the program I'm "stuck" with. You can request a referal from your PCP and go with the surgeon that is with the HMO. As long as it is not an exclusion in the policy, they have to refer you somewhere.... good luck to you!
   — w8free

July 19, 2003
If you have an HMO/ or PPO for that matter; your insurance MUST offer you doctors in the group (you said you doctor was out of network - was this your choice? ) IF the HMO does NOT have anyone in network that can do surgery; they must let you go out of network for 'in network' benefits... Check with your insurance commisioner...
   — star .

July 19, 2003
It's not impossible to get this surgery with an HMO, but it is challenging. Go to your PCP and talk with him/her regarding what you want and get them to refer you to someone within the HMO network that does the surgery. At the same time, explain that you've learned of the challenging obstacles to getting approval from an HMO. Make sure your doctor has documented in your chart all of your co-morbidities. Begin gathering up all your diet history IN WRITING. Get letters of medical necessity from your doctor an any other doctor you've been to who can contribute this to your cause. I have Cigna, which is often as challenging as Aetna. I had to have a 12-week physician supervised diet in the last 12 months. Wisely my doctor started this about the time I began to seek approval. I faced one denial, but I did appeal and submit these new notes and was approved. Hang in there. If you get all your ducks in a row and document EVERYTHING, you'll have a fighting chance.
   — Cathy S.