#53043 03-01-2006 04:54 AM | Joined: Feb 2006 Posts: 136 Gold Member (100+ posts) | OP  Gold Member (100+ posts)
Joined: Feb 2006 Posts: 136 | I have a Humana HMO and just found out the CCC I had intended to go to tommorrow is out of network even though they accept Humana. It is out of my local network and they ahve to get pre-authorizations to cover the visit. Not sure if it will get approved or not.
Has anyone else ran into this situation when trying to go to a CCC that isn't in your immediate area? Did they approve everything or did you have to fight for every claim to be paid?
SCC Right Lateral Tongue T2N0M0 Dx 01/12/06, Surgery 01/25/06. Partial Glossectomy, Bilateral Neck Dissection - 22 lymph nodes - all clear. No radiation.
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#53044 03-01-2006 05:43 AM | Joined: Feb 2006 Posts: 136 Gold Member (100+ posts) | | OP Gold Member (100+ posts)
Joined: Feb 2006 Posts: 136 | Just got off the phone with both the RO office and Humana. Have to get a pre-authorization letter to Humana before the visit so they can approve him (even though is he part of the Humana Network already - just not my local network). The insurance company won't let me do the claim - it has to be started by the doctor, and he already has a full schedule today and can't do it today, so looks like I either chance it and keep the appointment and risk having to pay $500 (what the biller said the charges would be) for it instead of the $15 copay or reschedule for at least one more week out - which makes the consult appt 6 weeks out from surgery. I don't know what time frame you have to start radiation for it to be effective - but I imagine that is approaching rather quickly.
This is all so frustrating! And, since my surgeon isn't recommending radiation at all - he probably wouldn't be willing to write the letter saying I need to go to the CCC (at least for the consult).
SCC Right Lateral Tongue T2N0M0 Dx 01/12/06, Surgery 01/25/06. Partial Glossectomy, Bilateral Neck Dissection - 22 lymph nodes - all clear. No radiation.
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#53045 03-01-2006 07:32 AM | Joined: May 2002 Posts: 2,152 Patient Advocate (old timer, 2000 posts) | | Patient Advocate (old timer, 2000 posts)
Joined: May 2002 Posts: 2,152 | Where is this doctor today? Is he in surgery and can't be interrupted? If not,I'd march my a.. into his office and demand that he sign whatever piece of paper you need. I doubt he is turning you down, it is probably the front desk because he is booked today. Don't they understnad this is CANCER and can't wait. Go make some waves. You don't want to wait another week.
Take care,
Eileen
----------------------
Aug 1997 unknown primary, Stage III
mets to 1 lymph node in neck; rt ND, 36 XRT rad
Aug 2001 tiny tumor on larynx, Stage I total laryngectomy; left ND
June 5, 2010 dx early stage breast cancer
June 9, 2011 SCC 1.5 cm hypo pharynx, 70% P-16 positive, no mets, Stage I
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#53046 03-01-2006 08:14 AM | Joined: Feb 2006 Posts: 136 Gold Member (100+ posts) | | OP Gold Member (100+ posts)
Joined: Feb 2006 Posts: 136 | The doctor that I want to see hasn't seen me yet - and doesn't feel he can write a letter. My ENT doesn't think I need it - so I'm not even asking him to write a letter - since I doubt he would and my primary care doctor is uninvolved and I doubt even knows I had the surgery. So, guess I'll just forget about it. Maybe the ENT is right anyway and I really don't need to do anything but wait and watch.
SCC Right Lateral Tongue T2N0M0 Dx 01/12/06, Surgery 01/25/06. Partial Glossectomy, Bilateral Neck Dissection - 22 lymph nodes - all clear. No radiation.
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#53047 03-01-2006 09:19 AM | Joined: Mar 2002 Posts: 4,912 Likes: 52 OCF Founder Patient Advocate (old timer, 2000 posts) | | OCF Founder Patient Advocate (old timer, 2000 posts)
Joined: Mar 2002 Posts: 4,912 Likes: 52 | God forbid that something negative happens to you. But if it does, be sure that you hire the most vicious attorney that you can find and teach Humana a lesson they won't forget. You know you will have our support here no matter what direction this all takes. If something does go south down the road, I want to be on the receiving end of the first call that you make.
Brian, stage 4 oral cancer survivor. OCF Founder and Director. The first responsibility of a leader is to define reality. The last is to say thank you. In between, the leader is a servant.
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#53048 03-01-2006 09:28 AM | Joined: Feb 2006 Posts: 136 Gold Member (100+ posts) | | OP Gold Member (100+ posts)
Joined: Feb 2006 Posts: 136 | The insurance isn't that bad as long as you stay in your local network. But, the conversation on the phone was kinda like "if we determine there is someone in your city who can provide the services...." So, even if I got a waiver letter written by one of these doctors, they might deny it anyway. Plus - as you stated in another post question of mine - if I'd have to get the treatments there as well if I wanted to go with the doc at the CCC(due to legal reasons) they'd probably deny that as well since there are several rad centers in Cincinnati in my network.
Getting the PET scan might be another issue since I read today that it is one of the "excluded treatments" from the plan's coverage.
SCC Right Lateral Tongue T2N0M0 Dx 01/12/06, Surgery 01/25/06. Partial Glossectomy, Bilateral Neck Dissection - 22 lymph nodes - all clear. No radiation.
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#53049 03-01-2006 11:34 AM | Joined: Feb 2005 Posts: 2,019 Patient Advocate (old timer, 2000 posts) | | Patient Advocate (old timer, 2000 posts)
Joined: Feb 2005 Posts: 2,019 | Amy, I am gathering from this you haven't asked your ENT. I think you should. From what you said in your message to me about his training, I would think he'd support you going for a second opinion from a CCC even though his opinion is that you don't need rad. Don't make the assumption he won't without asking him. And ask him ASAP. Rattle some cages, girl, before you give up on this! This is your health and life we're talking about here!
If you go there, and get an opinion from a CCC that you need radiation, I doubt your local hosptial will ignore that opinion. They will probably "reevaluate your case" and come with the same opinion (I know this because this is what happened to me) and you'll be covered for the treatment.
Nelie
SCC(T2N0M0) part.glossectomy & neck dissect 2/9/05 & 2/25/05.33 IMRT(66 Gy),2 Cisplatin ended 06/03/05.Stage I breast cancer treated 2/05-11/05.Surgery to remove esophageal stricture 07/06, still having dilatations to keep esophagus open.Dysphagia. "When you're going through hell, keep going"
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#53050 03-01-2006 02:05 PM | Joined: Mar 2004 Posts: 417 "Above & Beyond" Member (300+ posts) | | "Above & Beyond" Member (300+ posts)
Joined: Mar 2004 Posts: 417 | Amy, A physcian died and when he reached the pearly gates St Peter stated "You have done no harm, you may enter". A Minister died and he too was rewarded with entry into heaven.
An HMO administrator died and when he got to St. Peter he heard th following "OK, you may enter, BUT, you can only stay three days!
Have Faith
Darrell
Stage 3, T3,N1,M0,SCC, Base of Tongue. No Surgery, Radiationx39, Chemo, Taxol & Carboplatin Weekly 8 Treatments 2004. Age 60. Recurrence 2/06, SCC, Chest & Neck (Sub clavean), Remission 8/06. Recurrence SCC 12/10/06 Chest.
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