Any experience getting Kaiser to allow out of network treatment

Folks:

I am 46, recently diagnosed.

Kaiser is my insurance.

Been a little less than thrilled with them so far. I had a PSA of 3.99 two years ago but they never recommended a biopsy.

And I can't get a straight answer from anyone on how many procedures their surgeons and brachy guys have done.

So I went to Johns Hopkins for a second opinion.

They reclassified me from a Gleason 6 to a 7 and told me a ton of stuff that Kaiser really didn't.

Wondering if anyone out there has been successful in convincing Kaiser to pay for treatment outside their network?

Aachen

I'm with Kaiser, used their D.C. guys with mixed results. The whole point of Kaiser--for good and bad--is that they do everything themselves.

In the Cleveland area, Kaiser has limited in-house services. They farm out tertiary care to bigger hospitals here like the Cleveland Clinic.
So it might depend on the local Kaiser organization. The smaller the local Kaiser organization, the more likely they would use other providers. Good luck.

I have a friend who was diagnosed with Pca and has Kaiser insurance. No you can't go out of network. For some reason they are only giving him surgery or 32 appointment radiation. His numbers aren't that bad but for unknown reasons they have ruled out brachytherapy. He just has catastrophic coverage with a high deductible so he's elected to wait until medicare kicks in for him which is like 5 months away. Then he can see other doctors.

I'm a retired federal worker who back in the late 70s when first hired chose Kaiser HMO. Aftrer a couple of years never talking to anyone higher than a nurse or a physician's assistant I realized one day when I took my dog to the vet was why couldn't I ever see a doctor, when my dog always did every appointment. I dropped Kaiser soon after and never regretted it. In fact if I had kaiser I never could've had my TFT.

Obamacare is to be implemented in the next few years. With a hostile House trying to defund it at every turn. So I wouldn't count on it until I see what actually goes into effect. I know that doesn't help you or anyone else in our age bracket awaiting medical treatments but it is what it is.

How did you just find out today that you may have an abnormal prostate? If it's done by DRE it depends on who does it and I had doctors feeling a bulge and not feeling. I trusted the 3D saturation mapping biopsy more than anything else and it was the most correct as seen now years post treatment.

Aachen said...
Ziggy:

The MRI results weren't available when I had my initial consult with the radiology guy. He just read them today. That's what prompted his call to me today.

My Kaiser urologists haven't contacted me with MRI results yet.

I'm reviewing my notes from Johns Hopkins to see if I just missed it in their review with me.

What little I know and read of MRI it's not an ideal tool for Pca. Actually few have that done. I'm guessing John Hopkins didn't do an MRI. Ask others here about the validity of MRIs with Pca.

Aachen,
I did use the Capitol Hill Kaiser for my cancer treatment, after "firing" the Virginia unit for not seeming as engaged in my case as I thought they should have been. Dr. Behari, the head of Urology at Capitol Hill, was my surgeon. He told me he had done hundreds of surgeries, and that seemed good enough for me. (This was before I had discovered HW, which I wish I had done BEFORE treatment instead of after.) I liked Dr. Behari, and the unit in general, and was VERY impressed with the facility and staff. The new Tysons Corner mega-facility hadn't come on line yet. However, as you can see from my profile, I had a complication following surgery that caused me quite a lot of suffering. Perhaps I was just more active too soon than I should have been, or maybe it was their fault, I'll never know. I would say that a cystogram before catheter removal should be mandatory to rule out the possibility of leaking BEFORE they take out the catheter. Since then, everything has been great and I'm getting zero PSAs, so I'm feeling OK about the experience overall. Incidentally, upon my diagnosis, when I asked to see a radiologist, they immediately referred me to one of the D.C. area's top-rated brachytherapists, Dr. Tonneson at Fairfax Inova, so I don't know why they wouldn't do that for you. He told me I was disqualified for brachy, I believe because my prostate was too large.
Overall, I love belonging to Kaiser. From where I was before, a small businessman struggling for many years to pay for insurance I could never use because the deductibles were so high, my Kaiser Medicare Plus card is the most precious thing I own. And go look at Kaiser's ratings from Consumer Reports--they beat every other plan in the country by a wide margin, so they must be doing something right. Can you find better doctors, better hospitals, better treatment somewhere else? I'm sure, if you look hard enough and can afford it. So go do that if you can. But for a little guy like me, I'm very happy with my situation. I've had a lot of medical intervention in my life, mostly from top doctors at top hospitals, and like everything else you buy, some of it was great, some not so much. I'd like to always have the very best auto mechanic, too, but basically it's a crapshoot. Better now, with the proliferation of information on the internet, but still a crapshoot.
I hope this helps, and I wish you the best.
Henry

Aachen,

Giving up an established insurance contract to count on what is supposed to happen in 2014 would be extremely risky, if not worse. The provisions you are talking about have not kicked in yet, and different states will have to decide if/how they will proceed.

My thought is to work within what you have, and be planning how you could deal with any out of network cost issues now, so that there are fewer surprises (there are always some unpleasant surprises in any major medical "adventure").

 

Folks:

Thanks for the feedback.

One problem I have is that Kaiser is not nationwide.

Right before diagnosis I was in the middle of a move to Austin TX.

No Kaiser there.

I'm self employed so that makes me ineligible for the plans that will allow you treatment out of network based on geography.

Sadly this is not what I was told when I signed up years ago.

Sortof hate the idea of having to live in only a few states just to maintain coverage.

But you are right in an overall sense. It's a crapshoot out there. Particularly in TX, which has a state government extremely hostile to Obamacare and health care generally.