Can you demand a HMO to pay for an out-of-network surgery if no surgeon in-network can perform the surgery?
I hаνе a hip condition thаt nο surgeon іn mу HMO's network саn operate οn. Whаt obligation dοеѕ thе HMO hаνе tο pay fοr аn out-οf-network surgeon tο perform thе surgery?
That depends upon the terms of your contract with the HMO.
Good luck. HMO's are not in the business of keeping people healthy. They are in the business of securing profits for their shareholders.
I would think you have the right to appeal, and get them to pay. Ask them, because you sure are entitled to it (i think).
If your primary care physician is aware of this, it is up to them to negotiate with the HMO on your behalf. However, they can still make you pay the out of network premium for the surgery. Welcome to the world of HMO. Others making decisions for your health care. Think that stinks, wait until we get socialized medicine. Then the government will decide what and how you are treated.
We have 2 health care systems in Australia-public (what Americans would alarmingly called socialized) and private. Private health insurance companies would never tell doctors/patients what/where they can have any particular treatment (excluding cosmetic surgery). The government does not interfere in the public system either. Everything is done for free (excluding elective cosmetic surgery). A lot of wealthy countries have free health care for all. People who know anything about the USA health care system thank their lucky stars they don't have to deal with it (and I'm talking about wealthy people who could pay for top insurance). There is a lot of scaremongering done by the spin doctors working for very wealthy and powerful interest groups who want to keep the status quo. They want everyone to think 'socialized' means 'communist' with all the negative qualities that that conjures up.
No 'bean-counters' anywhere in any system should be interfering in a doctor patient relationship and deciding what treatment you should or shouldn't have.
Sorry about your condition and sorry that you live in America.