PART 13: HMO V. PPO

9/11/13 Update

Posted September 11th, 2013 by Mark Ghiassi

HMO V. PPO

We have to decide this month to choose HMO v. PPO.

Last year around this same time, we had to make the same decision. We chose HMO because both Mark and I thought I was in “recovery” and we did not understand how Cushing’s affected my whole body.

Three months after our first surgery, we trusted all our Doctors advice and chose HMO believing the Cushing’s was gone, resulting in out of pocket costs of over $40,000.00. Emotional stress and time expended on appeals to the Department of Health. There is no price to place on what was lost.

As you know, the first surgery failed, and now oddly enough, my second brain surgery was three months ago, and we are faced with the challenge of making the same choice.

 The answer is simple: Change to PPO.

 The problem: the cost

POSITIVES:

•          The monthly cost of the PPO is the same as the HMO. 
•          We will not be stuck in a specific IPA group with doctors who are not specialized or who don’t believe in my disease. 
•          There is a doctor at UCLA, an endocrinologist that Mark and I saw at the Cushing’s convention. He is in the blueshield network (preferred). He would not have performed the surgery. We want to make an appointment with him so we can get an expert endocrinologist in Cushings who can evaluate my progress to see if my local doctor is on the right track. 
•          The only other expert is out of network but in Los Angeles as well. However he does not take insurance and would be more expensive.   Many of the other Cushing’s patients have used him and have positive results.

 If we had the HMO, we would have to prove there was no other doctor in our group that qualifies in order to get a referral to him. The plan could choose not to authorize this. The plan does not understand my disease and I am tired of fighting every step. It appears that a lot of specialists are starting to step away from being providers for some reason and doing cash based only.

NEGATIVES:

•          COSTS: Our co pays will increase for both my primary doctor and specialist.
•          We will have a deductible that we have to meet before the PPO starts paying. There is a yearly cap on what we will pay if we choose preferred physicians.
•          If we choose a non preferred provider (ex. My second surgeon Dr. Kelly is out of network). The PPO could authorize some payment but there is no cap to what we would pay. However, at least some of it would be paid unlike this second surgery. DEFINITELY IMPORTANT.
•          The cost of labs and testing will not be covered as much as with the HMO. Currently I do not have to pay for labwork, the HMO covers it. Of course this did not stop the HMO from sending me bills this last year and me having to argue every step of the way.

The bottom line: the benefit of the PPO to be able to go to doctors of our choice outweighs any other aspect.  The best chance of recovery is to make sure I am treated by doctors who know how to treat me. This year we are going to try PPO and see what happens.  Remember I am only three months out of surgery, it was about six months in when the doctors finally confirmed the tumor was not removed and three months later (wasted time on appeals) that I had the second surgery.

 Please continue to forward our website to anyone who may help. This is going to be a long long road for us. Disability is still pending. I am trying to do my book keeping but I am managing six hours a week.  They have not weaned me off the cortisol, this will take over a year to do. Every time I decrease I will become exhausted and suffer withdrawal again.  There is also no guarantee that my adrenals are working correctly due to the Cushings’ tumor.

Everyone knows I am not a negative person but I have to state the reality of what is going on here medically. The less stress I have over the next year the better the chance for recovery and remission. 

When we end this page, if anyone wants updates,please send us a response by email to mdghiassi@gmail.com. I thing I am going to create a blog so anyone who wants to check in on us can. We are trying to create a list as to who wants updates so we don't bother everyone. Thanks for all your support.

Love Michelle