HMO Nightmare

Last month in BI 003: HMO vs PPO, I thought I made the clear-cut choice for my family health insurance plan by going with HMO. After a month of struggles, I may not be so sure. I know with a HMO, I need a primary care physician (PCP) first who would recommend me to a specialist if the need arises. Since my wife is pregnant, Cigna allows us to select an OB/GYN without a PCP’s referral, or that’s what I thought.

Hospital

Since we were starting from scratch, we started our search with the hospital we wanted to deliver in. We found the perfect one, one city over. We then scrolled through their roster of doctors and found one that we liked. Simple right? Wrong.

Medical Group

I called up the doctor to schedule an appointment for my wife. The office manager asked, “What medical group are you with?” I smugly answered, “Cigna HMO”. She fired back, “That’s your insurance, but I need your medical group!” After some back and forth, apparently I still needed to track down a PCP, who belongs to a medical group. The PCP and the OB/GYN need to belong to the same medical group to be considered in network. I thought I was a smart guy when I suggested she give me a PCP that they use. Viola!

HMO Limitations

Although the OB/GYN can deliver at the hospital we selected, it will not work for HMO patients, only PPO. Wow. You get what you pay for.

Wrong City

After a few days, my wife and I decided to switch OB/GYN’s because we only chose the first OB because of her connection to our favorite hospital. In talking to my Cigna rep, the PCP that was referred to me for the first OB would have been out of network so it was very fortunate I called. They belonged to the same medical group, but in different cities. Wow.

Déjà vu

After selecting our second OB who was more experienced and had better ratings, I had Cigna match the OB with a PCP in the same medical group. Cigna would make the change to my wife’s PCP. Finished? Not so fast.

Transition of Care

On a Monday, Cigna’s transition care specialist called me up and wanted to discuss two items. She noticed the last PCP we chose was in a city very far from our home. Before she made the change she wanted me to understand that the hospital we would be able to deliver at would also be very far away. Insanity! Secondly, the specialist offered me the transition of care option. In special cases, when a customer switches insurance or if a doctor leaves the network, a customer can file for transition of care, within 30 days, so they can continue to use their current doctor or specialist and have then temporarily be in network. Please check with your insurance company to see if this applies to you.

Final Thoughts

There was additional stress because my wife needed to get her monthly exam soon. Jumping through all these insurance hoops, I felt we wouldn’t be able to find a doctor for her in time. The transition specialist followed up and found a PCP in the same medical group and the same city as our new OB/GYN. If you are going through similar struggles, your best bet is your insurance company. Doctor office staff are usually the last to know. Our first visit is the first of the month so this saga will be continued. Holy HMO Batman!

Stay Inspired!
Buck

39 thoughts on “HMO Nightmare”

  1. I can totally feel your pain Buck. Considering the amount of money these companies charge, you would expect a better system in place.

    Why not have one number and track everything through that?

    1. I always dealt with my PCP so I never felt this pain. There are so many moving parts. Insurance companies, medical groups, doctors, and specialists. They all don’t have the same information or one part misinterprets the coverage which grinds the machine to a halt!

  2. This sounds like a big hassle. I totally understand. Sometimes dealing with insurance is a nightmare. That was absolutely one of the worst aspects of my previous job. Hopefully, these are the only insurance problems that come up until your wife delivers!

  3. I’ve never done an HMO and stuff like this is precisely why. Our PPO mandates that you stay in network to get the best percentage payments, but it’s never been an issue to find a participating physician. Nothing having to jump through hoops like this, anyways. Good luck.

  4. I agree with Krantcents. We had an HMO for many years, but luckily everyone we wanted was “in network” and we didn’t have a real choice of hospitals.

    This process you described seems like a lot of waste for the system. There’s got to be a better way….

  5. I work for a company that is a combination managed care organization/HMO. And Ive dealt with these issues in a specialists office, too. Trust me, the offices are as frustrated as you are not just being able to go by the insurance but having to go by insurance AND PCP. I know we were.
    But in addition to the insurance company regulations, each state has a number of laws regarding womens health and transition of care for pregnant women. No one wants to make a pregnant woman switch doctors.

    But I agree, start with your insurance company. Work with customer service, and if theyre not helping you, ask for more specific help. You have a transition of care specialist. She is going to be your best resource because this is what she does all day long- help people new to this insurance find the right physicians and service for them.
    If more serious things come up, ask to be assigned to a care manager. This person, usually a nurse or a social worker, will help guide you through any serious health issues, making sure that every step you are making is covered.

  6. What a nightmare Buck. I hope it is all resolved smoothly for the sake of your ongoing and pressing healthcare requirements. It’s stressful enough preparing for a new baby without the added stress of navigating through the insurance system.

    Health insurance should be a non-profit business. It’s the only humane way.

    1. Depending on your state laws, health insurance may very well be a non-profit business. The state of WA does not allow any health insurance provider (not even the Blues) to operate as for profit within the state. However, companies have to make enough of a margin to pay their employees (including COL raises and merit raises) and the laws require gobs and gobs of money in reserves.
      As far as I can tell, unlike life insurance carriers who get to claim “acts of god” and not pay out life insurance when lots of people die, your health insurance company has to be able to pay is 50% of their covered lives all had to be in the ICU or undergoing cancer treatments at the same time.

  7. What a huge hassle! I’ve never had any experience with anything other than Kaiser which I got on about 14 years ago when I married my present wife. Prior to that I had nothing and rarely went to the doctor. Now that I’m older I’ve required more medical attention. I love Kaiser as everything is convenient and self contained. My doctor is right next to the hospital and care has been excellent so far.

    Sorry you’re having so many problems. With a young growing family you’ll need good care for you and your wife and kid(s).

    Lee
    Have you heard about the A to Z Video Challenge?
    Blogging from A to Z
    #atozchallenge

  8. When my wife got pregnant the second time our insurance had changed. We couldn’t use the same OBGYN. We decided to pay for her visits and work it out with her. We got lucky because 5 months into her pregnancy she got a new job with insurance that covered it all.

    Jai

  9. Insurance companies are ridiculous, the number of stories I hear like yours really makes me think if this will ever get better or if they will always try to find ways to make your life more difficult by adding hoops to jump through. Does it really have to be this complicated?

  10. All of this is better than the Army hospital where I delivered my first. I had a different doctor each time I went for a checkup and the doctor that attended while I was in labor said adios as I was being wheeled into the delivery room….ah the good old days!

    I’ve never dealt with an HMO and hope to God I never do!

  11. Oh, insurance companies…they are all the same. They charge you awfully lot of money, and when you need their services, it turns out that you are not fulfilling their conditions, or just partly filfilling them. Gosh, I hope it turns out well for your wife after all!

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