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An HMO Saga

I cannot get my GP or Gynecologist to give me a referral to MDA cancer center. They both said my Insurance would not allow it.(HMO) Advice?

I have to go to bed now as I have a bit of a hangover from my pity party(angry party?) yesterday and i can't possibly read or think another thing today! :)

donna

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Dear Donna,

I suggest that you tell your GYN and your GP both:

" If you are stating that you are letting the HMO decide what is medically
necessary for me on the basis of finances, then you are ripe for a
malpractice suit. I suggest that you justify this referral medically, and
let me worry about suing the HMO instead of suing YOU. "

"The AMA has specific guidelines about second opinions, here they are" [link
on this website's page on "Patients' Rights" ]

"If you do NOT know that sarcoma centers have much higher survival rates for
their patients, and CONTINUE to make it difficult for me to be seen at one,
you are seriously not practicing medicine correctly, and I will report you
to the state medical board as well."

And change them for better doctors, if at all possible.

Get in touch with the HMO management and start making noises about how they
are going to get their pants sued off them.

However, all of the above has to be done much more delicately.... BUT IT IS
YOUR RIGHT TO HAVE A SECOND OPINION, and they cannot deny that to you.

There are other HMO people who have dealt with this... and there is a
patient advocate center online that can also help. I am hoping that others
will chime in here.

doctordee

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Dick, Donna has LMS stage iv lung mets, needs referral to a sarcoma center, and sarcoma oncologist and her HMO doctors are refusing it. She lives in TX, needs information about Texas laws to make the HMO and its docs sit up and take notice.

Her doctors are really creepy and really do not understand LMS at all. [Her gyn onc allegedly said she didn't need surveillance...that the margins were clear and go home and enjoy.... and then was surprised that there were lung mets, as this was a uterine cancer...]

If I hadn't already cut my hair very short because of the chemo shedding, I would now be pulling it out in handfuls ANYWAY...
doctordee

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Dick's answer to Donna's HMO crisis


Dear Donna:

Get hold of the Texas Board of Insurance.

Consumer Information - HMOs

http://www.tdi.state.tx.us/consumer/cbo69.html

Texas Department of Insurance - Complaint Form/Insurance

https://www.tdi.state.tx.us/apps/perlroot/s_cp_complform/complform.html

Texas Department of Insurance - Physician/Provider Complaint Form

https://www.tdi.state.tx.us/apps/perlroot/s_cp_prcompform/prcompform.html

[He here gives a contact that he worked with at the Texas Dept. of Insurance for HMOs, her fax and email, and her direct number. Their help line is 1-800-252-3439 ]

If you are going to see a Sarcoma Oncologist at M.D. Anderson that would most
probably be M. Andrew Burgess. If a surgeon Dr. Pisters, radiation either Dr.
Ballo or Dr. Zagars. The link to the departments is down but here is the main
M.D. Anderson link: http://www.mdanderson.org/

Also for patient advocacy issues and information see these sites from the
Patient Advocate Foundation

http://www.patientadvocate.org/

http://www.patientadvocate.org/resources.php

If you file a complain be sure that you also contact your State Rep, State
Senator and U.S. Congressman at the very least.

**If you write a letter and the HMO is resisting sending you to a specialist
DEMAND that they provide you a list of physician/oncologists who "customarily
treat" LMS rare cancer. VERY IMPORTANT.


Dick






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