These Documents Provide Helpful Information
To schedule an appointment, please call 714-456-2951. Please be prepared to provide insurance information so that we can verify your benefits and obtain any authorizations that may be required.
If you have PPO insurance, our services are generally covered under your plan. The portion of the charges that are your responsibility is based on your benefits. If we are “out of network” and not a “preferred provider”, in general, you do have coverage when receiving care at the Center for Reconstructive Urology. However, the amount your carrier pays for services, based on percentage of “usual and customary” charges, may be reduced. Please note that we are often able to secure “in-network” levels of coverage when providing care to patients who are “out-of-network” when referred to Dr. Gelman by their “in-network” Urologist given that specialty care outside of the network is required and comparable services are not available within the network.
Services are provided at the University of California, Irvine Medical Center. Charges include professional and facility fees, and the facility fees are usually covered at the in-network level, as UC, Irvine is contracted with Blue Cross, Blue Shield, United Health Care, PacifiCare, Aetna, and most major health plans.
Most patients with HMO insurance require a referral for the medical services to be covered. If you have HMO insurance and are referred to Dr. Gelman, we contact the Medical Group of your health plan and obtain the necessary authorizations with a letter of agreement. Once this is obtained, your HMO should cover all charges except for any co-pays or other fees that are based on your benefits.
We have received authorizations to provide patient care to those with HMO coverage from these insurance carriers: Blue Cross, Blue Shield, Universal Care, Cigna, Primecare, Scripp, Samsun, Monarch, St. Jude Heritage, Gateway, Talbert, St. Josephs, Genesis, ADOC, Prospect, Hemet Medical Group, Santa Barbara Medical Group, BC/BC of Arizona, CalOptima, Riverside Medical Clinic, Sharp, Temecula Valley, Beaver Medical Group, Memorial Health Care, Redlands Medical Group, Mercy Physicians, HealthSmart, and others. If your carrier is not listed here, contact us so that we may begin the authorization process on your behalf.
HMOs may deny the request for referral and make no provision for treatment. This decision can be appealed and is often a very time consuming process. In cases where a delay in care can be associated with patient suffering and preventable complications, we make the effort without compensation to document this to the insurance carrier. Certain patients eventually become so frustrated with the appeals process that they simply give up, and choose to go without care or delay treatment until they can obtain alternate coverage (we believe that this is often the objective of the HMO).
In some cases HMO administrators will not deny treatment but “re-direct” a patient to another Urologist within the network. This is done contrary to the medical advice of the referring Urologist. In some cases, this is related to hospital contracting as the health plan may be contracted with UC, Irvine, but also contracted with another hospital at a lower rate. In every case where this has happened in the past, the patient was re-directed to a doctor who was not exclusively specialized in male urethral-penile reconstruction. If authorization is denied, we then contact the heath plan to determine the reason for denial and offer documentation of the quality and cost effectiveness of the care we provide.
We maintain a database for every patient we have ever seen, and can usually provide that particular health plan with the outcomes data using patients of that particular health plan. This is a very time consuming process on our part, as we often are on hold and/or transferred to the voice mail of those who do not return messages. We send fax justification without reply. We provide Medical Directors with Dr. Gelman\’s pager number and indicate 24/7 availability and yet may still not receive a response. We do this because we know that if we do not make this effort, the patient will usually not receive care.
Despite our efforts, certain HMOs will simply refuse to honor the referral of their own network Urologists. When this happens, the patient can choose to be seen without coverage, or schedule an appointment with the doctor selected by the insurance administrator. In many cases, since the re-direct is to a Urologist who, like the referring Urologist is also not specialized in male urethral-penile surgery, that doctor will often document that the patient needs care at our Center, and then we are usually able to obtain authorization. In some cases, the insurance will then re-re-direct and re-re-re-direct the patient seeking a network doctor will agree to assume care. However, this is rare.
HMO insurance plans are required to authorize care when appropriate care is not available in the network.
There have been several cases where patients were actually re-directed to our Center. One example is a patient who underwent prior artificial urinary sphincter placement by another Urologist and required further surgery. The HMO re-directed the patient to Dr. Gelman. However, when Dr. Gelman contacted the patient, he indicated that he wanted to receive care by the doctor that did his initial surgery. In response, Dr. Gelman refused to see the patient, and instead, for free, wrote a letter to the HMO explaining that we do not accept patients who are established patients with other doctors and want to continue their care elsewhere for this reason. That HMO then approved care with the other doctor.When a patient is re-directed to a Urologist who agrees to assume care, it generally does not matter that the referring Urologist documented that the care should be provided by Dr. Gelman or that the patient wants to receive care at the Center for Reconstructive Urology. It does not matter if the other doctor is not fellowship trained and/or not exclusively specialized in male urethral-penile reconstruction. It does not even matter if the doctor accepting the patient previously performed failed surgeries on other patients re-directed to that doctor by an HMO and then underwent a successful re-do surgery by Dr. Gelman.
When an HMO re-directs a patient to a doctor who states that he/she has expertise in the surgery we perform and is comfortable providing the care, then the only option for the patient to receive care at our Center is for the patient to be seen without insurance coverage for the professional or facility fees. In most cases, the patient then chooses to receive care elsewhere rather than be seen without coverage. Over the past 12 years, we have often seen re-directed patients return after failed surgery elsewhere with recurrent problems that are more complex. We can then generally obtain authorization to provide care, which often includes re-do surgery.
Out-of-Town and International Patients
Many of our patients travel from outside of the Orange County and Los Angeles areas for care. We routinely see patients from Central and Southern California, Nevada, and Arizona. Patients also travel from other states (20 to date) and other countries to receive quality care at our center. All care is coordinated so that appropriate treatment is provided in as few visits as possible. We are always happy to provide guidance in the planning of travel.
Patients with urethral stricture disease often benefit from testing such as urethral X-ray imaging at the time of initial consultation. Dr. Gelman contacts every patient in advance, and if testing is indicated, it is done at the time of the initial consultation. We have an imaging facility within our office and Dr. Gelman personally performs all imaging when indicated. The UC, Irvine International Relations Department offers assistance with the travel arrangements for our international patients.
Please arrive 15-20 minutes prior to your scheduled appointment to complete registration paperwork. If you received previous care, you are encouraged to hand carry records to the appointment. Many patients request that records be faxed to our Center, but we have found that when these requests are made, the records for whatever reason are not available at the time of the appointment. In contrast, if you hand carry your records (including any films) and hand them to Dr. Gelman, we guarantee that they will be available at the time of visit. Please click here for maps and directions.