Question:
Where to go from here. A little confused? Atena Ppo-open Choice

I am in the process of trying to get an appt. with a Dr. in Pittsburgh for laproscopic gastric surgery. I got a call from the Drs. office requesting that I call my insurance company to see if my Dr. is in the "network". I found out the unfortunately he isn't but the hopital he does the surgery is in the network. I was told they do cover the insurance if it is "medically necessary." I was also told since I have an open choice policy I have a $300 deductable & am responsible for 30% which is about $7,000. Which don't get me wrong is better than nothing. So I called the Drs. office back & told them what I had found out. She asked me if I still wanted to go through with the appt. I told her yes. She said that they will put through a request to my insurance co. for this & will note the account I okayed it & am aware of the costs. Now I'm just a little confused. The insurance company said they will cover it if it medically mecessary. The Dr. hasn't even see me yet. So how can they send in an insurance claim with out any back up for medically necessary??? Please if someone can explain the insurance mombo jumbo to me. If I don't have to pay $7,000 that would be nice. I asked the office at the Drs. office if there was anything that can be done & she said no. So what can I or should I do now. Please feel free to email me. Thanks for you help!    — Allison T. (posted on June 10, 2001)

June 9, 2001
Hi, my first thought when I read your question was maybe you could look into finding someone in your network. I see that you live in Youngstown. I looked into the database here and found a surgeon in Toledo that accepts your insurance and does lap surgery. His name is Dr. Kligman. There are many wonderful comments from his patients. They seem to really admire him. The doctor on your profile is in Cleveland. Are you wanting to switch in order to have the surgery done lap? If so, then you may want to see if Dr. Kligman is in your insurance network. This would save you some money. Also, Claudia the secretary is supposed to be exceptional-according to the comments. She would probably be able to answer your insurance questions and send for approval. I read one comment by someone with your insurance that she got approval over the phone. BTW-one comment by a member was that they had originally gone to a surgeon in Pittsburgh, but the place was a zoo. It's probably not the same surgeon, but I found it interesting. That member's name and e-mail address are listed, it would be interesting to ask them. I am sure that you have researched, however I think that I would try and find a surgeon in my network. I used this site, when I was first searching and I found my wonderful surgeon. He is in Middletown, Dr. Fallang. He does the procedure lap, but mostly does open. Hope this was helpful. Good luck on your journey.
   — Shelley.