Editor's note: If you have questions about the practices of your managed-care coverage, ask the experts at the Department of Managed Health Care. They take up issues ranging from difficulties getting an appointment to denial of a doctor's recommendation for treatment.
My 16-year-old daughter was diagnosed with supraventric- ular tachycardia. At times, her heart beats so fast that she has to stop what she is doing or she will pass out. There is a procedure that can stop this and allow my daughter to live a normal life, but the only doctors who can do this procedure in our HMO network are adult internists. We requested authorization to have the procedure done by an out-of- network pediatric cardiologist, but our request was denied. I do not want my daughter to have a procedure done on her heart by someone who only has experience with adults. Can you help?
– Jodi Albalos, Folsom
If consumers have an option on choosing health plans, they should consider that a PPO or a POS will typically offer greater choice when it comes to where, or from whom, an enrollee receives treatment.
Many people choose an HMO because they are easier to understand.
Employers offer health plans tailored to many different needs and priorities. The three most common types of health plans are health maintenance organizations (HMOs), preferred provider organizations (PPOs) and point of service (POS) health plans.
In general, enrollees in an HMO plan agree to receive care from that health plan's in-network doctors.
However, if a health plan's network does not include a doctor, a specialist or access to special equipment to provide the appropriate level of care for a specific situation, an enrollee can request authorization to get that care out of network. Except in emergencies, enrollees should always get author- ization from the health plan prior to receiving out-of- network care.
Although the HMO denied your request, the Depart- ment of Managed Health Care sent it through the independent medical review process to find out whether it was medically necessary to have this procedure done by a pediatric cardiologist rather than one of the health plan's available adult specialists.
The physician reviewer decided that in your case, it was reasonable to request a pediatric referral, and the HMO denial was overturned.
If you think you think you need care that isn't available within your health plan network, don't forget that you are entitled to a second opinion.
To ask a question, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
