Run around from Medicaid HMO

[nightngail7]

Does anyone know where I can get help? I have a problem with a mega colon. mega rectum , colon inertia & what appears to be intestinal pseudo obstruction. I also having large internal & external hemorrhoids that I need to have removed. am on a medicaid HMO in the state of NM. I have been getting the run around from my Medicaid HMO for over a year. I was sent up to the University of Colorado where I was seen by a GI Dr. & then a surgeon who only saw me for 10 minutes.. I was denied an appeal from the HMO to go out of network and out of state to a facility that provides the type of GI motility testing including anal rectal testing  and  a consult with a colon rectal surgeon who is familiar with my condition. I was seen at Mayo Clinic in Scottsdale my last visit was  about 6 years ago  but they will not except out of state Medicaid & either will Mayo in Rochester. I finally got a referral to Cedars Sinai in Los Angeles after a letter was written on my behalf from the GI Dr. I saw @ the University of Colo. I have an appointment to have an antroduodenal manometry test done. Both my small bowel & gastric emptying test appear to be normal & the GI Dr. I have seen in El Paso feels I don't need this test. My Medicaid HMO has a contract with Cedars Sinai for me to take the test and I am being forced to go there and take the test or they will no longer help me. My primary care Dr. is saying that I need to go or the door will be closed. . The Director of the plan states this is not the case and I will only be able to go to Cedars Sinai once just for the test . Even if there was a problem I can't get the right treatment & if there is not I can't get the surgery consult . Cedars Sinai surgeons will not accept the out of state Medicaid. I have spoken with a GI Dr. at Mass General who will have an insurance rep talk to my plan. I am afraid the HMO will not let me go there. Does anyone have any suggestions for help with the insurance & for GI motility & colorectal surgeons-Thanks!

[Amir Mostafaie]

Dear nightngail7,

With an HMO plan, your Primary Care Physician manages your health care needs. In more complicated or acute cases, a “case manager” is assigned to help with the treatment process. Some are through case management companies and subsidiaries of insurers or third-party administrators, while others are independent vendors.
Ideally, a case manager is assigned to facilitate an early intervention and treatment which means more effective medical management & a shorter length of treatment & that is a win-win situation for both the patient & the carrier. I would recommend asking your plan Director or Primary Care, if they are able to assign a case manager for you.

Keep in mind, your Primary Care will advise you based on his/her experience, but the plan Director will advise based on rules & regulations (and they try to be politically correct).

Sincerely,  

Amir Mostafaie