Jimmy R.
I am an attorney. So, while I thought of hiring my own attorney, after it was all said and done, I argued my own fate. If it helps, I can forward you some of my letters, and appeals.
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 Presbyterian, 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.
l am happy to discuss further with you. I left out some of my arguments, but tried to throw the book at them, and lucky for me, they ducked, and I won!. email me, because I can't always find time to check the forum for posts, and I check my email far more often.
RON.
