insurance question

[apostol]

Hi - my husband is scheduled to have AN surgery in November with Dr Golfninos at NYU.  Dr G accepts our insurance and is in our network.  The surgery and hospital stay will be submitted through Dr. G's office and should be covered.  The only problem is that Dr G teams up with Dr Roland and he does not participate in our health plan and we have no out of network coverage.

I've been told that we will need to pay his $400 consult fee out of pocket and that when it comes time to the surgery they will submit a pre-cert to the insurance company to see what they will cover and that we will be responsible for the rest. 

This doesn't seem fair to us - we did not choose Dr. Roland - we chose Dr. G who is in our network - we can't help that this is who he partners with do do this surgery. There are a limited number of physicians who can do this type of surgery and we chose one in the network but we can't control who he works with.  It seems to me there should be an exception and that perhaps the insurance would cover his expenses since we have no choice in the matter. 

My next question would be if the insurance company makes only partial payment to dr. roland would it be fair to try to negotiate with him and see if he will accept what the insurance offers or reduce the balance that might be expected?

does anyone have any experience in this type of situation?  I'd appreciate any advice.  thank you . . .

[lori67]

Hi and welcome to you and your husband.

Unfortunately, all of us here seem to have more experience dealing with insurance companies than we ever cared to have.

My situation was fairly similar to yours - my surgeon was in network but the hospital was not.  (Does that even make sense??).  Anyway, I have what's called a "catastrophic cap" clause in my insurance that says the most I would have to pay out of pocket for out of network providers is $1000.  So, my insurance picked up the whole tab except for that $1000.  I was going to call and fight with them about it, since obviously my surgery needed to be done in a hospital, but I figured when it comes down to it, $1000 for brain surgery seemed like a bargain to me and they let me pay it a little bit at a time.

You should check with your insurance.  I don't know what they expect you to do if they don't offer you any options.  It's not like your husband is having his tonsils out and can pretty much go to any hospital he wants.  AN surgery has a little more limited availability and you should be able to chose who does it.  If you don't have any luck with the insurance company (ask to speak to a supervisor when you call), then I would explain the situation to your doctor.  I'm sure he'd be willing to work with you on a solution.

Good luck.  I've been fighting with my insurance company since last December - it gets very frustrating, I know.  Hang in there!
Lori

[Debbi]

Hi Apostol-

Well, I had the exact same situation - and the exact same doctors.  I did end up paying the initial consult fee with Dr. Roland of $400, but it is possible that you might be able to negotiate that down at least a bit.  I'm insured with Aetna and they were not particularly flexible.  However, they covered the entire surgery and the after care without any problem. (Just not that initial consult.)  Dr. Golfinos' office will make sure the surgery and follow up (for 3 months) is all covered - at least they did in my case. 

For what it is worth, both doctors are excellent and I would pick them both again in a second if I had another AN (heaven forbid!)  I've had some post surgical facial paralyis and see Dr. Roland every month for that - he's tops in my book!

What kind of surgery is your husband having? 

If I can answer any questions about the doctors, feel free to PM me.

Debbi

[Mickey]

Hi Apostol,  Even though I`m watching and waiting at the moment I am using the same Drs. as you. My problem is in reverse. Dr Roland excepts my plan while Dr. Golfnos dosn`t.  I spoke to them both about this problem and they seemed to be willing to work this out. I didn`t get into specifics just said to me if that time comes they will explain. I would go over everything with them and I`m sure that they will work it out for you. If it`s only a consultation fee of 400 that don`t seem to bad.  I wish you the best of luck. Please keep us posted, Mickey

[jtd71465]

I was in the exact same position with the same doctors.  Call me if you wish to talk.

Joe-

[Jim Scott]

Apostle:

I'm sorry you and your husband have to deal with this but at least you have health insurance.  Getting it to cover what it should cover is another matter.  Because Debbi, Joe and others who've already replied to your post have dealt with the same doctors, they should be able to offer you some very useful advice. 

I can tell you from my experience that you can successfully negotiate with insurance companies, hospitals and doctors.  Most reputable doctor's offices will be quite willing to work out a payment plan for any large fees you may owe, as will almost all hospitals.  I did this with the relatively small parts of my AN surgery expenses that weren't covered and it worked out just fine.  In most cases, if you ask them, doctors will also send the insurance company a letter explaining the necessity of a procedure or whatever the insurance company requests, as this is ultimately in their best interests, financially and for your good will and peace of mind. 

Insurance companies are harder to deal with but they can be tractable if you approach them with facts, stay calm and civil and always try to deal with a supervisor, not just a representative, who usually doesn't have the authority (or knowledge) to see and implement the exception that should be made in your situation.

The bottom line is that these expenses can usually be negotiated and it is certainly worth your while to do so.  You have a very logical case regarding one neurosurgeon who is a part of your insurance company's network partnering with another doctor who isn't in the network.  You didn't choose the second doctor.  That is a relevant fact that may alter your insurance company's decision but of course, if the contract language states that they don't have to pay the fees of an out-of-network doctor, they are legally covered, no matter the unfairness of their decision in your specific case.  You may well be liable for the $400. consulting fee, but if so, that likely can be paid in increments and, as you suggested, Dr. Roland may consider adjusting his consulting fee in your case, but that is his decision.  I doubt he is under any legal or ethical obligation to do so.  Let's hope he is used to these situations and has some compassion for you and your husband as well as understanding that this situation (AN surgery) is stressful enough with his adding to it.

Please let us know how this works out, via this forum.  Your situation and how you surmount it can be helpful to others in the same circumstances.  Oh, and welcome to the site and the forum. 

Jim

[apostol]

Thanks to all of you for your input and advice.  I look forward to speaking to Joe and Debbi in more detail about their expereinces with Dr. Golfinos and Dr. Roland.  I'm sure I'll be back with more questions and concerns as we proceed through this journey.  Thanks again, Jennifer.

[HeadCase2]

apostal,
  I also had one DR on the team who was "out of network".  Once the primary surgeon sent a letter to the insurance company that this surgeon was critical in the outcome of the surgery that requires a team, and would actually save the insurance company money with a good outcome with less complications, they [CIGNA} paid.
Regards,
  Rob

[goinbatty]

I'm not sure if this will help but in some situations, if there is not a comparable physician (same specialty) within say a 50 mile radius, the insurance company may cover as in network.  It depends on the plan language, but your surgeon would need to request this of course prior to the procedure.