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[molli_sols]

Without going into too much detail, I am under an HMO and I was referred to a specialist in May by my primary care physician.  The case is still waiting review from the specialist, and back in May they said the earliest they are scheduling initial appointments is October.

In the meantime, the problem is not solving itself and it is impacting my career.  Can I call up the offices of some other specialists in the area and ask for an earlier appointment?  Do I then go back to my PCP for the referral or do I go to the appointment to get a diagnosis first?  If they confirm the diagnosis, can I then go back to get insurance to cover treatment?  Or, should I call my physician and ask for a referral somewhere else right from the start?

I really want to avoid telling my physician how to do her job by asking for a certain treatment, but even if I was wrong in what I suspect is the issue, the specialist would point me in a better direction. 

[oseph]

Call your insurance company and explain the situation.  See what they recommend doing.  Last thing they want is to shell out for an emergency hospital visit because you couldn't get regular non-emergency care.  Obviously they are going to be bastards about trying to make you wait until October, but it is worth trying anyway to see if you can get the go-ahead to call around to other specialists covered by your plan, sans referral.

[inthelab]

Sometimes it is worth it to pay out of pocket and suck it up.  The cost of the specialist's visit is, what, the price of a couple of dinners out?  Check and see.

My anecdote, FWIW.  My mother's HMO wanted to do back surgery for pain related to restenosis of her lumbar region. She didn't want surgery again.  I made an app for her with a neurosurgeon at #1 hospital in America, a short drive from where I live.  She brought X-rays.  Neurosurgeon took 1 look at X-rays and said there was no restenosis (with Mother's permission, he asked me to be there to see the X-rays myself).  He wrote a treatment plan involving PT and pain-killers.  Cost: $125.  Did her HMO pay for the visit? No.  Did they do what the neurosurgeon recommended? Absolutely.

[molli_sols]

Thanks for the responses.  I'm new to this whole having-health-insurance thing. 

[inthelab]

I really want to avoid telling my physician how to do her job by asking for a certain treatment, but even if I was wrong in what I suspect is the issue, the specialist would point me in a better direction. 

Actually, to a certain extent, your physician is your employee.  If your think there is something to be explored for the sake of your health, you should tell your physician and your physician expects to hear from you.

ITL, faculty at a med school

[t_r_b]

Without going into too much detail, I am under an HMO and I was referred to a specialist in May by my primary care physician.  The case is still waiting review from the specialist, and back in May they said the earliest they are scheduling initial appointments is October.

My wife had a similar situation a couple of years ago. The issue was significant pain in a particular joint that forced her to give up hobbies she enjoyed and limited her ability to do her work: not a minor problem. First it took a while just to get the MRI. Then it took a month or two to get in to see the resident, who didn't actually do anything other than say, "you should come back to see the specialist." It took months more to get in to see the specialist. Once we did, he was great. He told us not to get surgery and to ignore any joint specialists who recommended surgery (using the, "if you have a hammer..." analogy). Instead, he suggested she work with the vocational rehab specialists in the neighboring unit at the hospital.

Trouble was, the HMO then decided that it had physical therapists on staff who did injury rehab, so why should she go to the hospital to see the vocational specialists? Um, because the specialist they had paid to evaluate her injury said they knew better how to handle that particular kind of injury? Sorry, no dice. I don't know that that injury ever got adequately treated: as far as I know (we aren't speaking these days) she just figured out how to suffer through it.

It's worth pointing out here that the HMO suffers absolutely no penalty for allowing my wife's injury to persist for months or years untreated. The longer she goes without treatment, the more money they make. And if the condition ever does develop to a level of severity that requires expensive medical intervention, they will almost certainly be off the hook, since they won't be covering her any more.

It really pisses me off that the health care debate so often focuses exclusively on the uninsured. Yes, it is appalling that so many people in this country lack any health coverage at all. It is also appalling that many more people than that have health coverage that is so miserly as to be dangerous. We have a system in which the companies in charge of authorizing and paying for care have very very strong incentives to discourage people from getting care, and they do. The ridiculous waits for specialists are part and parcel of this problem.

I agree with ITL. In this system, it is not only erroneous but dangerous to assume that following your doctor's instructions will in itself make you healthier. Too much of the system (such as the wait for referrals) is beyond the doctor's control. Instead of counting on their doctors, people have to advocate vigorously on their own behalf. Be assertive with your doctor about your concerns. If the doctor can't help, take it to the HMO. Make noise.

The squeaky wheel gets the grease. The well-oiled wheel just keeps spinning in circles until it dies.

[janedoh]

If you do decide to see someone on your own, make sure that you know how much they will charge you BEFORE you go in. Out of network, you will no longer have the benefit of your insurance's negotiated rates. I got sick when I was between policies (and had only catastrophic coverage). The total between blood work and office visit (to my primary care doc) was just under $500, and this was 6 years ago.