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Dealing With An Hmo

Meleficent

By Meleficent
in Doctors

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Meleficent Rookie
Meleficent
Posted

Hello!

I am recently diagnosed (6/26). I am the first and only patient my primary care has seen with celiac. My GI gave me the name of the CSA, 2 restaurants I could eat at (but it ended up being just 1), and a list of foods I could purchase at Whole Foods with the note that my Dietician could help me. The dietician was a waste of time and money, cuz I learned more on my own in the week before my appointment than she gave me.

Here is my problem. I want to see a GI with experience dealing with Celiac. I know that there is some follow up care (6 month blood work to make sure system is healing and whatnot), also would like to have access to a dietician with some knowledge of celiac. PROBLEM -- I live in Chicago (a good thing) and my primary care through my HMO has contracts with 3 hospital groups -- none of which have any experience dealing with celiac patients.

Does anyone have any advice for finding a doctor with a contract into the hospital I want to be seen at? They will take me if I have a referral, but they do not take primary care in their system with a HMO. Oh -- and I want to be seen at the University of Chicago.

Many thanks in advance!

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debmidge Rising Star
debmidge
Posted

Every HMO has a Dept. which reviews cases after they've declined coverage. You must contact your HMO and find out where you must send your letter asking them to review your case. Use your documentation about how their plan is "berefit" of celiac speicalists, etc. Let them know that not all "gastro" doctors are created equal. Most know nothing about celiac and masquarade as "gastros."

The "court" so to speak of last resort for you is your State Dept. of Insurance. If your HMO turns you down after they did a final review you can contact your State Dept. of Insurance to find out what your rights are as a consumer. If you sort of tell your HMO (in a casual, nice way) that you'll be doing this if you get rejected they might take you more seriously. It's a gamble. The State Dept. of Insurance monitors all insurance companies and complaints from consumers ....so it's really not what you want to do first off...first off you do the letter for them to review the case again.

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