Healthnet HMO Experience

Unfortunately it is not good news if you have an HMO. In my experience, (I have Healthnet HMO) with an HMO you have to find a doctor within your network and also usually within a certain radius, mine was required to be within 50 miles of my home. The surgeon needs to be contracted with your insurance in order to qualify. When I was going through this process, it was prior to FDA approval so there were not many docs doing resurfacing let alone any in my area. They sent me to one at Stanford that claimed he did resurfacing but only did hemi-resurfacing.

I went to my PCP and had him specifically write a referral for me to get hip resurfacing. I requested a consult with Dr. Amstutz in LA, about 500 miles from where I live, I even changed my address once to my sisters who lives within 50 miles of Dr. Amstutz office. They denied me. I appealed and pretty much pleaded with them to get back to me soon because I could no longer function at work and my pain was getting to the point where I could not even go to the grocery store or get in and out of my car without being in horrible pain.

In my appeal letter (dated October 5)I told them that I was scheduled for surgery in India on December 1, to please get back to me before I left on November 26. The appeal process is supposed to take UP to 30 days, they took almost two months. They conveniently typed up my approval letter on December 1, knowing I would have had my surgery already. So, when I returned from India, I received approval to have surgery with Dr. Amstutz and denial for coverage in India. I was not able to get reimbursed, not even one cent.

But as I have said before, it was the best $12k I have ever spent. If I would have gone ahead with surgery here with Amstutz, I could have been faced with a bill of $23k. Dr. Amstutz stopped taking insurance shortly after this, so I am sure if I would have tried to schedule surgery, my insurance company would have come back to me and told he that he was no longer contracted with them and I would have been back to square one. They know you are in pain and they try to do whatever they can to make you give up. I chose not to deal with the added stress and I took my life and well being into my own hands. I was no longer willing to let the insurance company dictate my fate.

I have included the approval which also came with a statement from one of the insurance companies consulting orthos which states the reasons they should approve me for resurfacing.

Our health care system is in such a sad state. I feel for all of you that are going through what I went through. We will do what we can to help you through this.

LBHR Dr. Bose Dec 01 05