My ex-boss had an HMO. It sure made things more complicated -- had to go through a long appeals process to get them to pre-approve the visit. But she just kept sending them letters, having her daughter's doctor send the HMO letters & calling them every third day. I think she may have just worn them out, but they did give in & paid for everything except $1000. Mayo offered charity care for the $1K, but she was able to afford it.
Mayo reviewed all the girl's records & convened a team. They actually didn't run very many tests up there. Most of the tests were run ahead of time by the local hospital. Once they came up with a treatment protocol (maybe a week or so into her stay), they teleconferenced the girl's GP & explained everything that needed to be done. The GP arranged for the protocol to be continued in her hometown & the girl was released from Mayo back to her local hospital. Mayo handled any issues by phone for quite a while. Eventually she ran into a glitch & went back for a second visit at 6 or 12 months (or maybe both) b/c there was some specialized treatment that the local hospital couldn't provide -- and again that was a battle to get covered -- but the HMO paid for 100% of that visit.
So it is do-able. If you can find yourself a volunteer advocate, that would be ideal. Otherwise, you or your family need to be the advocate. Just call them like there's no tomorrow & keep asking for more information, for written records of everything & for the next person up the food chain. Document every phone call & send them records of what was discussed, what was promised & what you would like them to do.
Mayo is not like House. They do not do fly-by-night treatments or break the law or run tests that are unnecessary. The HMO's want to make it out like they do. They only run reasonable tests. The difference is that the Mayo doctors have seen the craziest cases in the country, so they hear a set of symptoms & immediately know what it is b/c they've had 12 other cases. Other docs maybe read about
that dx in one paragraph of one book back in med school.
Try the other suggestions that people have posted -- no need to go to war with the HMO if you don't need to, but I want to encourage you that it can be done. It just requires a lot of patience, a doctor with a lot of patience & a roll of stamps. Don't give up. We're all pulling for you. :)
Post Edited (Frances_2008) : 2/10/2011 1:07:45 PM (GMT-7)