Ellen,
My HMO plan wouldn't allow me to go to an experienced surgeon, out of my plan (out of state), so I fought and fought and appealed and appealled, until I finally got my way. MY HMO's fight, was the in plan, out of plan distinction. There was a guy in plan that could do this, but only had 40 procedures under his belt. Clearly a novice, as compared to Brackmann, who does hundreds of these per year, and thousands in his career.
I appealled to the end. The insurance doesn't think most people will. My plan had the final appeal as a panel of people, unrelated to my insurance plan at all, in a different state. The panel was a physician, nurse, and someone else in the medical field, totally unrelated to my insurance. My insurance had told me I could get microsurgery inplan from the novice, or go to Texas, and get Gamma Knife at a qaulifying or related hospital, with two other doctors. I did my research on those fellows, which were nice, but inexperienced, and left me feeling panicked at the thought of them handling my procedure.
I argued like crazy, picked apart my patient's rights, and other documents for anything I could stick my foot on and argue about. I argued that it had been my experience in dealing with my HMO, and through my entire appeal process and ordeal, that I have been specifically denied numerous rights granted to me as a member, while to my knowledge being in complete compliance with the payment of my premiums and all of my responsibilities under the Subscriber Agreement. As a result of the interference with my rights, I have not been able to adequately defend myself nor my position in this appeal process, nor have I been provided with all of the information necessary to me in this appeal.
I also argued that if a doctor didn't want to see me, they wouldn't force him to, and that as a patient, I should have the same choice. I thought that was taken well by the panel. I also argued that when comparing the track records of Brackmann versus the ones they wanted, the total experience, success rate, percentage of bad cases, etc. made it clear that there wasn't an in plan doctor of the magnitude that I could get out of plan, and that argument I think is the one that swayed them to let me go out of plan.
The monitoring, as I understand it and as it was explained to me, is an integral part of the procedure, and is necessary to ensure your safety as the patient, and the success of the procedure. I'd appeal their decision, and fight. I'd get as much literature or opinions of surgeons on this issue, and give them a fight. Don't delay surgery on the payment issue. If that's what you want, fight for it, appeal, appeal appeal, and fight for your rights.
RON.
