How do you get an insurance to let you go somewhere else?

[delvalle6]

So my son has been a patient at this hospital all his life. I don't particulary like the hospital. My insurance will not allow me to go anywhere else. He has been having more symptoms lately and the hospital will probably just blow them off. He is currently on Digoxin and Lisinopril and has begun to complain of lower right extremity pain off and on. He self-limits and cries if we ask him to excercise, so we don't ask him anymore. When he does excercise, he vomits. He is seven years old, bicuspid aortic valve- moderate stenosis- severe insufficiency, with aortic enlargment and left ventricular enlargment. They keep telling me that it's no big deal, but I feel differently.
How do I get the insurance to allow me to take him to another hospital? I have decided I don't like HMO's.

 

[kfay]

This is a new one on me, I've never heard of an insurance company allowing you to go to only one hospital. Can you change Dr.s? I would probably start there and try to find a practice that has a good pediatric cardio group. If you find a really good Dr., hopefully his problems can be managed medically at this point and not surgically.

Lisa in Katy is our resident insurance expert and I'm sure she'll be along soon with some insight.

Kim

 

[delvalle6]

I live in Vancouver, Washington and have Kaiser insurance. When I took my son for a second opinion to Legacy I had to pay for it myself- Kaiser would not cover the second opinion unless I chose a second doctor at the same facility. I do not particulary like that facility... The cardiologist is nice, but I always feel like I'm just going to fill a quota or something. Never really get the feeling that I have all the information or that my concerns are taken seriously. I always leave with the feeling I am making something out of nothing, and I don't really like that.

 

[Maryka]

There are other Kaisers in other parts of the US--though not many. In my area, the Washington DC area, there are a bunch of Kaisers, but I understand they let you go to regular hospitals around here (of which there are some good ones) that will do heart surgery for MY Kaisers. Also, the San Francisco area has Kaisers galore, though the SF area Kaisers may still try to force you to use their hospitals. (They have their own hospitals, I am told, in San Francisco area.)

Is there any other option for you--like a co-parent (like an ex-) who could co-cover your child? I have known people who manipulate Kaiser into reality if there is some sort of co-coverage.

It would be worth exploring, maybe? (I have vowed to NEVER choose Kaiser again in my area after some bad experiences there.)

 

[Lisa in Katy]

I would love to help, but I am no expert on HMOs, especially Kaiser. UHC doesn't have an HMO license in Texas, and really, HMOs are almost unheard of here. They tried it for a while back when, but we Texans don't take well to people telling us what to do!

Hint, if you don't like HMOs, you probably won't like what the government is trying to do to us!

 

[john79t]

quote
Hint, if you don't like HMOs, you probably won't like what the government is trying to do to us!
__________________

Amen. If they are comming up with a great deal for "all Americans" then do away with the gold plated government private health insurance and place the president, VP, congress and all government workers under the program. Not going to happen.

 

[Karlynn]

Our member Marty seemed pretty knowledgeable about Kaiser in the past. Maybe PM him and see if he has any suggestions.

 

[delvalle6]

I've argued with the "insurance" and offered to fly to other areas- but have been denied. Our Kaiser here in the Northwest just started a new Cardiac Program for Adults- and it is excellent... just not for Pediatrics.
My husband had an alternate insurance that we were going to use, but he has been laid off this entire year and lost the insurance, so our plan to go "around" Kaiser has been put on an indefinate hold. I've actually been applying for other positions at other hospitals in an attempt to acquire a PPO, but have been unsuccessful. It's really frustrating to be at the mercy of some Insurance guru who could care less about the patient health and only looks at the bottom line.

 

[Maryka]

Lisa and John--

You are upsetting me! If you were ever facing OHS without any insurance at all you would understand how bad our country treats health care delivery! If you are rich or have what you think is endless excellent health care, well hooray for you! BUT I have been without health care due to pre-existing conditions and I know this crap put out on some TV networks or right-wing talk shows is wrong, and, in my opinion, unconscioubable! Kaiser may be the pits, but, if that were my only option, I would take it. (My dear Marfan friend, Patricia, had 4 open heart surgeries and due to no insurance, had to declare bankruptcy 4 times. That is just so unfuriating to me!!!)

 

[catwoman]

Lisa and John--

You are upsetting me! If you were ever facing OHS without any insurance at all you would understand how bad our country treats health care delivery! If you are rich or have what you think is endless excellent health care, well hooray for you! BUT I have been without health care due to pre-existing conditions and I know this crap put out on some TV networks or right-wing talk shows is wrong, and, in my opinion, unconscioubable! Kaiser may be the pits, but, if that were my only option, I would take it. (My dear Marfan friend, Patricia, had 4 open heart surgeries and due to no insurance, had to declare bankruptcy 4 times. That is just so unfuriating to me!!!)

However ... would you accept a plan as your only option that told you you didn't need surgery, that your condition wasn't serious enough yet? And you couldn't go outside to another doctor unless you paid through the nose?
That happened to a friend. She had known for quite some time she had aortic stenosis. She worked in the medical field, was tied to using a specific group of doctors. One doctor said she needed AVR, then others said the numbers on tests didn't warrant it, wouldn't OK it and she couldn't get approval to go to another doctor.
She left that employer and was able to get insured through her husband. She finally had AVR this summer but it was several years in coming.

I am concerned that that's what we could be facing.

And it sounds like the same stance that delvalle6 is going through with her son.

 

[Lisa in Katy]

Exactly, Marsha.

 

[Maryka]

I am very saddened by the people on this list who do not understand what healthcare reform is all about. I am surprised that the moderators allow so much politics on this forum! People in the USA are dying every day because they have NO "new employers" to turn to for medical care. Just because most of us on this list seem to be secure in our preferred health care plans does not mean we should ignore that many Americans are suffering because they have NO Healthcare and they, like my friend Patricia, can get no backup healthcare from the states they live in or from anyone else. I think ignoring the fact that the US has deplorable infant mortality rates and that Americans die all the time due to lack of health care is unconscionable. I am sorry our Kaiser friend on this thread cannot "work" this current , cruel health care system, but I am glad she has at least an option, while others have none.

 

[Karlynn]

There is a thread already started that is discussing this issue of healthcare legislation in the US. I believe it's entitled "PBS interview". Can I suggest the discussion here (where good points were made) that doesn't concern Devalle6's specific issues move there?

 

[Tbone]

See if you can get your PCP to recommend a different facility.

Also, is this HMO a plan through your work, and does your work offer other choices. Would your employer give you a raise if you paid for your own insurance?

You do have the right to get new insurance without a preexisting condition clause since you are insured now. Have you looked into this?

There are many options for you to look into, and I hope you find your answer. No kid deserves to be in that much pain. I wish you well in your endeavor, and maybe someone else in this forum has a good idea for you.

 

[delvalle6]

My PCP did recommend another facility. My insurance denied it.
My employer is Kaiser, so the only insurance I am offered is Kaiser.
I cannot afford health insurance on my own and I will not get a higher pay for declining the insurance offered.

There are pros and cons to every insurance. What our system needs to realize it that insurance adjusters are not qualified to make medical decisions and should not have any influence over such decisions. Doctors should be treating patients. Insurance should do the financial part. There should be coverage for everyone.

Kaiser does a lot of non-profit stuff and is pretty good for healthy adults- or adults with cardiac issues...just the peds stuff seems to stink.

 

[Lisa in Katy]

Yes, but if they give us everything we want, the money has to come from somewhere, so guess where that would be? Our pockets! Kaiser limits their network to Kaiser because they are able to contain costs that way. You can take him anywhere you want, but it is out of your pocket. Might be worth it for a second opinion.

When you refer to him refusing to exercise, what are you trying to get him to do? What is causing him to throw up? Most 7-year-olds are more than happy to run and play, so I would be very worried if all he wants to do is sit.

 

[swim mom]

Which Kaiser Hospital are you going to? My cousin had Kaiser insurance and I seem to remember they have a hospital north of you like in the Camas area, several in Portland and even in Salem, I think. I would think you could go to other Kaiser hospitals in the area,

 

[delvalle6]

My son will sit and watch tv or play on the computer all day if I let him. It isn't really like him to be that way- he usually loves to play soccer and ride his bike... but I have been trying to get him and his brother to do some basic cardio every day- jumping jacks, sit ups, whatever-- anything. His twin brother Giovanni has started really following him everywhere, won't let Sammy out of his sight. If Sammy does nothing, that's what Giovanni does. So I try to get them up and moving, but Sammy just starts crying and tells me he can't. It breaks my heart.

Kaiser refers the pediatrics out to Doernbecher in Portland. Doernbecher OHSU is the only facility that Kaiser will approve. If it was a Kaiser hospital, I'd understand, but I just want to go somewhere else- anywhere at this point. I can't really afford to pay 100% out of pocket for a caring facility. The advice nurses are terrible. If I can get past them (which I rarely can) then the MD is ok. But do I want just OK for my son? Not really. I'm not asking for special treatment- not asking for anything outrageous- just for some compassionate nurses and some real answers. I can't get that at Doernbecher. I've been dealing with them for years now and they aren't getting any better.

 

[Lisa in Katy]

It is not healthy for him to sit all day, and probably making the problem worse. He will gain weight, if he hasn't already, and that's extremely hard on the heart. My advice is to ban the TV and video games except for a few hours each week. No one likes to do jumping jacks and sit ups, so find something fun. Go to the zoo and look at the animals. Go on a nature hike. Even if it's just walking, it's much better than sitting.

As far as providers, unless you can get a different health plan, or willing to pay out of pocket, you have to deal with what they offer. Personality conflicts aren't a valid reason for going out of network, no matter how much we would like it to be. Doernbecher is a large respected research facility, so I don't think you will be able to use the reason that they don't offer what you need. If I was in your shoes, I would pay for a second opinion just to make sure that another doctor agrees with what his current physician is saying. If they are in agreement, you have to figure out how to work within your system. If they don't agree, take it back to your health plan and see what they are willing to do then.

 

[delvalle6]

Lisa, It is unusual for him to be this inactive. I can't get him to do anything- he simply won't do it and starts to cry. He hasn't put on any weight.. he's actually lost some. His brother has put on weight... but not Sammy.

I wouldn't ask for a second opinion based on a personality conflict. The last time I called the advice nurse I was told "The only intervention left for your son is open heart surgery and the doctor thinks it would be best to wait, but if you really want to push forward you can make an appointment".
Her tone of voice was, well, condescending. I don't tell them what I do or where I work because I don't want that to effect how they treat me or my son. Either way, I do not think it is ok for someone to make me feel like crap because I am worried about my son's sudden lack of activity and lower extremity pain. That was just a small portion of what she said to me other than she didn't know what the lack of activity and lower extremity pain had to do with his heart. Didn't seem to me that she had a clue. As far as I know, the legs are vascularly connected to the heart- and since I work in a hospital and happen to work in the cardiovascular intensive care unit I would like to think I know a thing or two about it. The head surgeon here seems to think my son needs some medical attention- but they only do adults here.

I could tell you documented horror stories of my experiences at Doernbecher- like how they hung the wrong childs meds on my son's IV four times in one stay-- and I was the one to check the labels and make them pull the meds--or how they accidentally pulled out his chest tube after they gave him a pnuemothorax by turning up the bi-pap too high- then had to place the chest tube again... or how they told me that if I didn't consent to a blood transfusion that my son didn't need that they would take me to court..(they finally treated him with two EPO shots and he was fine)

If they are so well known and liked it is either for other departments or by people who have never been treated there--definately not the PICU or Cardiovascular department. They certainly aren't on the top 100. I have heard good things about the nuerosurgery there- but my son doesn't have issues that would require that department. I have heard some things about the OHSU portion that cares for adults- again, my son doesn't need those services.