My referral to see an off-post RE was denied.

FraggleChic · July 2011

This morning I had my appointment with my PCM (primary care manager) to seek a referral to the off-post RE in Olympia.
I saw my PCM less than three hours ago and my referral has already been denied. What I didn't know about the referral process is that my doctor on post would have to sign off on it. How is that fair when I'm requesting a second opinion!?!?!
The head nurse from the IF clinic on post just called and said that they won't refer people off post because "Tricare doesn't cover infertility." That's only partly true. How can that be true when I know PLENTY of people who are seen at off-post infertility clinics?! They will cover EVERYTHING except the actual IUI or IVF procedures. The clinic in Olympia says they bill Tricare all the time and that I just need a referral. My RE is refusing to give me one. This is so incredibly frustrating. I don't want to burn any bridges with the clinic on post, especially with my laparascopy scheduled for the 25th of August. It's a Catch 22 because I'd have no problem getting a referral to a civilian infertility clinic if we were at a duty station without one on post.

First, the IF clinic jerks me around for months because they can't see me when I need to be seen and now we have to wait an effing year for IVF. It's especially ridiculous because there's a perectly good RE who is ready and willing to see me NOW and who charges less for IVF than the cost on post, but I need that damned referral. So I'm stuck and right now I'm waiting to hear from the Patient Advocacy office. I really, really hope that they are able to help us.

MAbride0808 · July 2011

Ugh...I am so sorry. Is there anyone else you could get a referral from? Maybe you PCP?

BeeBee08 · July 2011

Uggghhhh, that is so frustrating! I'm so sorry it's not easier, I don't get it! I feel like they are keeping you and for no reason at all...they can't even see you when you need to! Geez, I mean if they could do your IVF tomorrow I MIGHT understand, but how can they hold you back from getting a second opinion?! I hope that your Patient Advocacy office can help you out. That's stupid.

FraggleChic · July 2011

MAbride0808:
Ugh...I am so sorry. Is there anyone else you could get a referral from? Maybe you PCP?

Apparently all referrals have to go through the hospital on post. They ultimately have the decision whether or not to refer off post. It doesn't even go to Tricare (my insurance company) without the say of the doctors on post. I was told that parents who want their child to see a pediatrician off post are at the mercy of the peds on post. If they say no, then the referral process goes no further.

I just don't get it. Off-post I can do IVF for about half the cost and I wouldn't have to wait a freaking year. All the nurse from on post said was, "I'll do my best to move you up on the list." Thanks.

naybird · July 2011

Ugh!! That's awful. Is there any way your PCP would help you file an appeal?

So frustrating! Good luck to you.

Mayan2011 · July 2011

AHhhh man. What a tough situation. I am so sorry you are dealing with this. I really hope the patient advocacy office is able to help you. ((hugs))

tootlebug · July 2011

why isnt your RE signing off on it? that's what i see is the problem. i dont understand that. ...does he not know the significance of an AMH test? it isnt the end all be all but it is definitely something that most REs look at in order to make a diagnosis and/or determine how to treat their patients.

are you looking to switch REs bc the other one in olympia is better? that just sucks, i dont understand why doctors dont give referrals when the patients ask for them. it's not hurting the doctor any. im sorry.

Bullymom0309 · July 2011

I am so sorry you are having such a difficult time with your PCM. I work for Tricare and we send military out all of the time to be seen by RE's. I do know that IVF, IUI typically are not covered. However, it is against the rights that you have as patient for them to tell you no, they will not send you out for a second opinion. I would also speak with the MTF referral manager and see if you can get somewhere with them as well. Good luck!! Move to the North region and you won't have much trouble Big Smile

FraggleChic · July 2011

tootlebug:
why isnt your RE signing off on it? that's what i see is the problem. i dont understand that. ...does he not know the significance of an AMH test? it isnt the end all be all but it is definitely something that most REs look at in order to make a diagnosis and/or determine how to treat their patients.

are you looking to switch REs bc the other one in olympia is better? that just sucks, i dont understand why doctors dont give referrals when the patients ask for them. it's not hurting the doctor any. im sorry.

The nurse told me they don't give referrals because "tricare doesn't cover infertility" which is total crap. They cover 100% of everything diagnostically and will cover everything for TI cycles. We are responsible for IUI and IVF OOP. If we stay with the doctor on post we won't be able to do IVF until July of 2012 because the waiting list is so long.

FraggleChic · July 2011

Bullymom0309:
I am so sorry you are having such a difficult time with your PCM. I work for Tricare and we send military out all of the time to be seen by RE's. I do know that IVF, IUI typically are not covered. However, it is against the rights that you have as patient for them to tell you no, they will not send you out for a second opinion. I would also speak with the MTF referral manager and see if you can get somewhere with them as well. Good luck!! Move to the North region and you won't have much trouble

That's what I thought! I spoke with the Clinic that I want to be referred to and she said the same thing. They have many military patients and bill Tricare for everything but the IUI and IVF procedures.

Bullymom0309 · July 2011

Just make sure that they accept prime benefits. A lot of times they accept standard and do not realize how many form of Tricare there is. Just be careful to make sure that all diagnostics are covered. i was reading on the Triwest website because each region is different on what they cover. From what I was reading they don't cover anything IVF. You also might look into another clinic that might be close by and just change the base that you are seen at. I am not exactly sure where you are located. Def go talk with the tricare office if you have an onsite location.

FraggleChic · July 2011

Bullymom0309:
Just make sure that they accept prime benefits. A lot of times they accept standard and do not realize how many form of Tricare there is. Just be careful to make sure that all diagnostics are covered. i was reading on the Triwest website because each region is different on what they cover. From what I was reading they don't cover anything IVF. You also might look into another clinic that might be close by and just change the base that you are seen at. I am not exactly sure where you are located. Def go talk with the tricare office if you have an onsite location.

We talked to them in January when we were having problems with the clinic on post. They could never get me in when I needed to be seen so we went to Tricare to ask for a referral, which they said they wouldn't give us because there's a clinic on post. I don't understand why a referral for second opinion is left up to the discretion of the first opinion doctor? That doesn't seem right.

I know a girl here who has Tricare Prime and did her IVF at the clinic I"m trying to get referred to. Tricare covered everything but the actual procedure, including her meds because of the way the doctor coded them. I don't get why I can't have the same chance!

tootlebug · July 2011

...so does the current doc just want the business then?? what is his deal? my OB didnt think i needed to go to an RE but would have done a referral anyways....my insurance doesnt require referrals but still, she would have done it.

MAbride0808 · July 2011

FraggleChic:
MAbride0808:
Ugh...I am so sorry. Is there anyone else you could get a referral from? Maybe you PCP?
Apparently all referrals have to go through the hospital on post. They ultimately have the decision whether or not to refer off post. It doesn't even go to Tricare (my insurance company) without the say of the doctors on post. I was told that parents who want their child to see a pediatrician off post are at the mercy of the peds on post. If they say no, then the referral process goes no further.

I just don't get it. Off-post I can do IVF for about half the cost and I wouldn't have to wait a freaking year. All the nurse from on post said was, "I'll do my best to move you up on the list." Thanks.

That really stinks! I am sorry.

Aegis2005 · July 2011

I'm so sorry - how frustrating!

labdemon · July 2011

It does seem really strange that the doctor giving the first opinion is "holding you hostage" from getting a second opinion.... I hope the patient advocacy people can help you get that sorted out.

Out of curiosity, I wonder how much it would be OOP just to have a consult with the new RE? Then at least you would know if you feel comfortable there and they could put together a better plan for you than the on-post people. If you hate the guy in Olympia, then I guess it would be a moot point, but if you love him, it would be worth jumping through the hoops!

Good luck! What a sh!tty situation.