[Miles42]

Is the a agency that helps with getting the run around from your health care provider? My wife is in constant pain from severe back problems. While I understand the need for her to see al possible solutions in the system the last DR we saw advised her due to the nature of her problem to see a Dr in Jacksonville. The Villages system insist she see another Dr who can not even see her until November and could not possibly do any surgery until Feb of 2017. Mean time she is in constant pain with very little relief.

[Sable99]

Have you tried Mayo Clinic in Jacksonville?

I am a huge fan of Mayo. Years ago, I went to several doctors in Adrian, Tecumseh, Ypsilanti and Ann Arbor, Michigan. Even had a laparoscopy (scope surgery) at St. Joe's Hospital in Ypsilanti. The specialists either didn't know what the problem was or said it was in my head. One doctor told me to go home and eat nothing but jello and cottage cheese for six weeks! Thank God I went to Mayo in Rochester, Minnesota two months after the laparoscopy and after the doctor who did the laparoscopy told me it was all in my head. Dr. Fish diagnosed me in 15 minutes!

[graciegirl]

Many PCP will not touch "pain management".

[golfing eagles]

Originally Posted by Sable99

Have you tried Mayo Clinic in Jacksonville?

I am a huge fan of Mayo. Years ago, I went to several doctors in Adrian, Tecumseh, Ypsilanti and Ann Arbor, Michigan. Even had a laparoscopy (scope surgery) at St. Joe's Hospital in Ypsilanti. The specialists either didn't know what the problem was or said it was in my head. One doctor told me to go home and eat nothing but jello and cottage cheese for six weeks! Thank God I went to Mayo in Rochester, Minnesota two months after the laparoscopy and after the doctor who did the laparoscopy told me it was all in my head. Dr. Fish diagnosed me in 15 minutes!

Glad you got the help you needed. Just remember that Mayo in Jacksonville is NOT Mayo in Minn., not by any stretch of the imagination.

[Miles42]

The real problem lies with the fact we went with the UHC system touted by the Villages this past January. With the health care plan we had before we could have gone to see the Dr in Jacksonville with no problem. Now getting the approval for anything has been a nightmare.

[golfing eagles]

Originally Posted by Miles42

The real problem lies with the fact we went with the UHC system touted by the Villages this past January. With the health care plan we had before we could have gone to see the Dr in Jacksonville with no problem. Now getting the approval for anything has been a nightmare.

Actually, the real problem is that all over the country for the past 5 years or so getting an insurance co. to approve a procedure, test, or out of network referral has been like pulling teeth. Your PCP needs to document in his progress note the exact reason for the out of network referral and why the same care cannot be rendered in network. That note gets sent with the referral request to the insurer, who will give an answer in 1-2 days. If denied, your PCP can speak with the medical director at the insurance co. and convince him to approve the request. It's a pain in the butt, however I never had a request denied after speaking personally with their medical director in 30 years of practice. But the yardstick HAS to be that the doctor in Jacksonville performs a procedure or specializes in something NOT available in network, not just my neighbor saw him or I like his biography on a website. These insurance co. rules are beyond the scope of TV Health, or any practice for that matter. But you should have had an answer within a week of seeing your PCP. After that, the waiting time to see this specialist is up to him only. Some insurers allow self referral to specialists, but less and less these days, and many specialists won't see a patient who has not been referred by a PCP. So don't assume it would have been any different with another PCP or a different insurance plan, not these days. Welcome to the new reality of health care in the U.S.---remember, "elections have consequences"

[Mudder]

I have had quite the opposite experience. Need to see a specialist in Boston for a little known condition. Went to Villages Health Care office in Lake Sumter, a customer service person did all the paperwork right there and then on computer, received letter of approval two days later from United Health Care.
Needed a referral to out of network doctor at U of F Shands, same thing, had the approval letter the very next day!
Of course there was a wait time of about a month for each specialist. The best part, co pay $15 each!

[golfing eagles]

Originally Posted by Mudder

I have had quite the opposite experience. Need to see a specialist in Boston for a little known condition. Went to Villages Health Care office in Lake Sumter, a customer service person did all the paperwork right there and then on computer, received letter of approval two days later from United Health Care.
Needed a referral to out of network doctor at U of F Shands, same thing, had the approval letter the very next day!
Of course there was a wait time of about a month for each specialist. The best part, co pay $15 each!

Which is why I think that either it was not properly done by the PCP in the OP's case, or the reason to go out of network was , well, dubious or possibly premature. No way to tell without knowing what tests and evaluations were done locally. Some doctors don't have the inclination to jump through the hoops to get the referral approved, some other doctors don't take the evaluation as far as they can before sending the patient to a specialist. Insurance companies are good at spotting both these scenarios. What they will never approve is a patient who "wants" to see Dr. X without a clear cut reason.

[jnieman]

Why not get a referral to a neurologist and a pain management doctor from your primary care doctor. The pain mgmt doctor may give her meds to keep her comfortable until surgery is available.

[Miles42]

We have gone through the pain management referral who could not help her. We where the referred to A Neurologist in Gainsville who after reading all the test said he could nor help her and reffered us to the Dr in Jacksonville. There is where we ran into the road bloack. Our PCP apparently does not know how to communicate with the Dr in Jacksonville and we where then turned down by our UHC people. They insisted we see this other Surgeon who can not be bothered before November. In the mean time the wife has constant pain and frustration awaiting all this BS.

[ronsroni]

Hi, Miles 42. I have some similar experience. If I may.
I have a Neurosurgeon in Ocala who is BRILLIANT and wields a phenomenal scalpel. He Is Dr. D. Robertson, Neuro. He does backs, necks and shoulders, I think. Real bright and exudes confidence; NOT condescending at all. There is no long term wait to see him. If you have ALL of your test records, surgery, etc; it's easier to get in to Dr. R. I have been a nurse for 40 years and I scrutinize all docs I encounter.
Please feel free to PM me if you have ??'s. I am a straight shooter and don't go for fluff.
Don't know what your insurance is but typically, the Ins Company DOES NOT SET THE RULES OF YOUR PLAN. Your plan does. Ins Co's enforce PREDETERMINED rules put forth by major carrier/employer info.. Crucial to be aware of this. By the way, I have UHC, TV and my neck fusion happened without hesitation.
Please contact me if you like. willing to share.......
Best.....

[Miles42]

Seeing the surgeon next week so we may get an earlier date. If not will look else where.

[jeriteri]

I have every little cartlidge left in both wrists. I didn't have any problem with my PCP referring me to a specialist for pain care. So I don't believe your statement covers all United Healthcare The Villages patients. Thank you.

[Miles42]

My statement refers to my situation only. I can not and do not speak for others. The surgeon today could not help her . She needs a seven point fusion and they are equipped to handle only two. She is now being referred to yet another Surgeon. Which was recommended all along a few months back. All while dealing with a constant pain level that makes her unable to do anything.

[outlaw]

Originally Posted by Miles42

My statement refers to my situation only. I can not and do not speak for others. The surgeon today could not help her . She needs a seven point fusion and they are equipped to handle only two. She is now being referred to yet another Surgeon. Which was recommended all along a few months back. All while dealing with a constant pain level that makes her unable to do anything.

Sounds like you are under the HMO/medicare advantage system?