Navigating GroupHealth Coop.

[jenbyrd]

Hi everyone!  Let me say that I am so glad that you all are here!  I have found many answers to my questions (and many new questions) while looking around the Forum.  It has been nice to get to nibble on a little information while I was waiting to see the specialist.

I found out I had a 1.5cm Right AN on 7/1/11.  Then, as scheduled, our family left the next morning for a week-long trip... and so did my ENT.  As you can imagine, the vacation wasn't the most relaxing. 

I live in Yakima, WA which is a relatively small town about 2 1/2 hours east of Seattle.  We have no neurotologists here, so I will need to go to Seattle (or Spokane). My insurance is GroupHealth Cooperative (GHC), and really it has been very adequate for us for the last several years, but now I'm a little concerned. Our plan has no out-of-network benefits, and I will need to have a referral/Prior Authorization to go to a specialist unless there is a GHC provider qualified for this diagnosis and treatment.  When I looked up GHC specialists, there is one (David Mehlum) who lists "skull base tumors" as a special interest, but when I try to research him online, I find nothing but 'HealthGrades' kind of stuff. 

I saw Dr. Mangham in Seattle yesterday and he was tremendously reassuring and obviously brilliant. If you Google Dr. Mangham, you will find, among other impressive things, endless references to papers, entries in professional journals, and textbook chapters he has authored or coauthored about ANs and other related issues.  During our consult, he explained the 3 treatment options and different surgical approaches. His suggestion for me was microsurgery using a retrosigmoid approach, based on the "favorable" location (mostly outside of the IAC) of my tumor.  Everything he said was in line with what we have been reading, and he answered all our questions with patience, knowledge, and just the tiniest bit of humor.  Did I mention that he was VERY reassuring?    I will continue to do research (every time I think I've done so much research that I must know EVERYTHING about ANs, I find more that I didn't know!), but really, I was put so much at ease by Dr. Mangham, that I am ready to get surgery scheduled for 4-6 weeks from now (kinda soon, but seems to work best for everyone's schedule and with any luck I'll be up and running for  Nathan's 4th birthday, our 10th anniversary, etc). 

Anyway, this all may be a pipe dream because of the referral/prior authorization business. Has anyone dealt with GHC and out-of-network providers and the Prior Authorization game?  I'm hoping one of you has some hints for how to make it go more smoothly (and in the direction I am hoping for).  Also, anyone who has experience and can just let me know a little about what to expect, I would appreciate it.

Thanks!
  Jen

[maryh]

Hi Jen,

Dr. Mehlum with Group Health in Seattle was one of my doctors as was neurosurgeon Dr. Kyle Kim, also Group Health.  Both of them are just absolutely excellent.  They have different personalities but work very well with each other and were great to me (and my family).  I had my surgery at the end of July, 2011 at Virginia Mason in Seattle (Group Health contracts with them for their surgeries.)  I am also covered by Group Health and live in the Spokane area, so I can relate to the out of town factor since you are in Yakima. 

I chose Dr. Kim and Dr. Mehlum because I was not happy with the ENT doctor here in Spokane, didn't feel that the neurosurgeon he works with in Spokane did enough acoustic neuroma surgeries though I did like the radiation doctor in Spokane.  I ultimately decided against radiation/gamma knife because of the radiation "bleed"  that can occur and potentially send you into surgery anyways.

When I was originally diagnosed with the acoustic neuroma, I wanted to take a wait and see approach.  The doctor here was not respectful towards me about that decision.  I had periodic MRI's after the initial diagnosis, never once did this doctor call to discuss the results (I had the written reports sent to me so I could read them for myself.)  I felt I could do better with a different doctor and I was right. When I sent copies of the previous MRI's to Dr. Kim, he called to talk with me on the phone before I met with him in Seattle.  We talked about a week before the actual surgery on the phone because I was nervous and he was very reassuring.  Hugely impressive.

Both doctors are easy to talk to, very reassuring and have hung in there with me during the lengthy post-surgery complications I experienced (which don't happen to everyone.)  I was back and forth between Spokane and Seattle from early August after the surgery through the beginning of November.  I've been home since the beginning of November, no return visits to Seattle, thankfully and am continuing to get stronger.

If you do have the surgery away from where you normally live, the doctors in your community will not want to treat you if you experience complications after you return home and will send you back to Seattle--so be aware of that.

On the insurance side, the Group Health coverage has been complete.  I also have secondary insurance through ChampVA, so whatever Group Health didn't pay for (which hasn't been much--they have picked up the lion's share of the expenses), the secondary has paid for.  It appears to me that providers have honored the contracted Group Health rate, charges in excess of it have not appeared in a separate billing directly to me (so far anyways.)

When you are at the hospital, Group Health assigns an Internal Medicine doctor as your "primary care" though you will still get daily visits from Dr. Mehlum, Dr. Kim and/or their very capable staff of Physician Assistants.  All of the Group Health Internal Medicine doctors at Virginia Mason were exceptionally smart, very personable and helped keep things moving for me.  I didn't care for one of the Group Health doctors I experienced at Sacred Heart in Spokane but she was the exception to all of the other doctors I did experience.

I hope this information helps--you may already have had surgery, but I wanted you to know what my experience was since I stayed "in network"

All the best,
Mary