Regarding the out of network doc, use the two standards of care argument.

Oh yeah, be persistant. I wrote a letter to the CEO and asked her if she knew about how lyme patients were being treated. Although I didn't get to talk with her, I had her assistant from her office calling me all the time asking if there was anything she could help me with. This assistant was at my appeal hearing as an observer

Cora
 

In addition, you might want to read the section on insurance issues in Karen Forschner's lyme book (see books in green menu box, left side of this page).

Another resource is the recent insurance issue put out by the Lyme Times (can google this).

If your HMO is denying your use of outside lyme experts, wait until you try to get them to pay for expensive treatments! If you are going to fight, maybe fight with them on potentially largest amounts of money, whatever that is. The doctor bills might not be the biggest cost.
 

But, I did go through the process. The way it was explained to me was that the primary doc needs to submit the request.

This was my biggest obstacle because I was told that she (the doctor) was not going to pay for me to be seen out of the network.

I didn't understand what she meant by this. I had insurance. Wouldn't the insurance pay for it?

What I later found out after going through 3 different docs and getting the same road blocks and calling the state watch dogs for HMO's and PPO's.......

Was...the doctor's sign a contract stating how much they will spend each quarter. If they go over this contract....they loose their bonus.

So, if the primary docs had referred me it would have been money out of their pockets.

It was suggested I see a doctor that was not on my insurance plan and have him or her write down what testing and specialists I needed to see.

I would then submit it to the insurance. The insurance would then deny it.

I then would submit it to the state watch dogs for insurance companies.

They would review the matter and then determine if the insurance needed to follow through.

This is where it gets tricky. They have guidelines.

I was told I needed to have a MRI of the lower spine because I was having difficulty with walking.

But, the guidelines said that I only needed to have an MRI of the upper spine and brain to check for MS.

I was told I needed to see a specialist at Stanford.

But, the guidelines did not concur.

So, I lost out on both requests even though I did go through the process.

In the meantime, the doc that I paid out of pocket was the one who knew enough about lyme disease to test me with IGenex.

So, I had a label for what was knocking me on my butt.

Since, it has been suggested you see a lyme specialist, it is worth a try to go through the process.

It was a very long process for me and I had all ready started treatment with the lyme specialist.

And my insurance had run out but they would have gone back to the time it was active if things had been approved.

It seems business is first and then your health with the medical field now a days.
 

But, neither one of them were interested in my health.

They said the insurance would only approve a consultation.

They said they had tests that could be done but the insurance would not approve it.

I inquired how much it would be to pay out of pocket for these tests. I felt they did not want to rock the boat or in this case bite the hand that fed them. (the insurance company)

So, they said they didn't think it was a good idea to do the testing. So sad.

Basically, they were working for the insurance company and I was on my own in order to get my health back.

Bug them untill they pay up.

MADDOG
 

This time I bookmarked your invaluable links. Thanks for organizing!