convincing an HMO to cover a "higher volume" surgeon

[oksandra]

Hi,

I was recently diagnosed with AN.  I don't have the exact measurements in front of me but it is about 2.6 cm on the longest side.  It is touching my brainstem a bit.

Anyway, through a really caring doctor who is a friend of a friend, I have found out the neurosurgeon who does the most ANs in the state of Oklahoma (and who apparently has a good reputation with this doctor and the neurosurgeon he spoke with).  Of course, he is not on my HMO.  I am going for a self-pay consultation with him on Monday.  I am wondering if anyone has had luck convincing an HMO that it is in their best interest to pay for a more experienced surgeon so that they won't have to pay for the complications afterwards?  I've seen some research on the internet about better outcomes for AN in high volume hospitals, but that may be referring to places like House.   The surgeon who does the most in Oklahoma does maybe 1 or 2 per month and has been doing them for maybe 15 years.  The surgeon on my insurance has been doing them for four years and he does 6-8 per year.

It seems that if it will be potentially cheaper for the HMO, and certainly not more expensive, then I'd have a reasonable case.  I think my PCP is willing to help on this, but I think I better figure out how to do it.

Sandra

[sgerrard]

I think people have the most luck when one of their doctors, say the neurosurgeon your PCP spoke with, recommend that particular surgeon. They can state the medical need, based on proximity to the brain stem, for a particular expert, and the HMO usually won't want to argue with that (since they are not neurosurgeons).  AN surgery is rare enough that the HMO should not be worried about a precedent or trend; it is more a rare and exceptional case, where normal rules don't need to apply.

Good luck!

Steve

[oksandra]

Thank you.  That is very helpful.