Quote:
Originally Posted by Dubious
Hi Kathy, It's definately an uphill battle. Usually, an HMO will pay for treatment that is available within their IPA. So I doubt there is a doc who is experienced with ketamine therapy in your group. Now, if a certain therapy is not available within your IPA, then you can argue with the insurance carrier that it is an absolute medical certainty that you need this therapy and demand a referal outside the IPA which they would be on the hook for. The IPA, HMO and your state will all have appeals processes to employ for this. My guess is that where they unfortunately will trump you will likely be their determination that ketamine is an "investigational" procedure for which is just a flat-out exclusion on the policy, ending all approaches. It would then be incumbant upon you to "prove" that ketamine was an accepted standardized type of treatment and it would also help if you had some professional papers, peer-reviewed studies with controls, to bolster your position. It's a stretch, but it can be done! You could also speak with an attorney but you would need to show further damages from you not getting the ketamine as the Knox-Keene Act goes a long way to protect them.
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Thank you, Dubious...
Very imformative, well written note..Yes...I have heard both reasons from my MVP ins. company as an arguement NOT to cover me..the final "put it bed" point was out of network services.. I even called to scream at them and the same..can't do it answer as ..dear friend of mine who is in HR of my co. looked up my policy claiming they are acting accordingly, sadly..My next attempt was then for them to tell me who in my network will perform this procedure...and they came up empty...so in my mind.. I am forced to act out of network then ..
They want to wear us don't and they are!!
Hugz, Kathy
