Need Help Understanding Prior Authorization and PPO vs. Medical Group

Hello,

I’m seeking advice on navigating health insurance for my husband’s recent cancer diagnosis. Here’s our situation:

He has Medi-Cal (Blue Shield Promise Health Plan) with Altamed as his medical group. We want treatment at City of Hope, but Altamed denied our request because it’s out-of-network. We appealed and got a one-time approval to see a specialist, but due to administrative errors, it didn’t work out. His symptoms are worsening, and we’ve spent the last month going back and forth with insurance. We were able to get another one-time appointment with City of Hope but received a call yesterday saying that the request was denied again. We tried to change his medical group for better care, but since he went to the ER in July, we were told he couldn’t change it until August.

We have an opportunity to switch to a commercial PPO due to a qualifying life event, but the deadline is tomorrow per the 60-day deadline. Family and friends are willing to help us pay for a commercial PPO plan.

I have a few questions:

Prior Authorization: If we switch to PPO and keep Medi-Cal as secondary insurance, we were told prior authorization might be needed for certain treatments. What does this process entail? Has anyone dealt with this and can share their experience? PPO vs. Medical Group: What are the pros and cons of switching to a PPO compared to staying with the current medical group? Is it worth making the switch given the complications we’ve faced? Oncologist Recommendations: Does anyone have recommendations for oncologists or treatment centers that work well with Medi-Cal or PPO in LA County?

We’re feeling overwhelmed and want to make sure he gets the best care possible without further delays. Any advice, experiences, or insights would be greatly appreciated. Thank you all in advance.

TL;DR: Husband diagnosed with cancer; facing insurance issues. Considering switching to PPO with Medi-Cal as secondary. Seeking advice on prior authorization, pros and cons of PPO vs. medical group, and oncologist recommendations in LA County. Deadline to switch is tomorrow.

submitted by /u/toffee_tkp
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