When and who and how to deal with insurance company about surgery

[Tricia (horsekayak)]

Ok, I've been doing my homework, and have visited or phone consulted with several docs in the atlanta area.  So far, the only insurance charges to blue cross ppo have been for co-pays for  doctor office visits, so blue cross PPO is as of yet unaware that i'm getting ready to spring AN surgery plus a BAHA on them.

Question:  i have now narrowed my choice down to shands and house.   I will be doing phone consults with eeach of them this upcoming week as soon as a VERY uncooperative Atlanta neurosurgeon (who will NOT be doing my surgery thanks to his customer NON-service and his relative lack of experience) sends my mri report/notes/diagnosis notes to me for forwarding to shands and house.

One question i have for anyone here on forum: , is when to talk about the insurance, how to file, how to get pre-approval, etc..  Atlanta docs i've talked with have said they have "staff" to handle it, but trying to get someone to call me has not worked out really well yet.  After persistent message-leaving, I  recently found out the approximate cost of the surgery, and even that was like pulling teeth just to get an "unconfirmed" estimate.  The hospital billing office basically told me i'd have to submit the bills after surgery  and just see what the insurance co (blue cross ppo georgia) would pay.  I thought the docs offices submitted things like that, and i thought they'd have more specific advice for me than what i got.

I'm in georgia and shands is florida, house is LA.  SO, i'm out of network for blue cross of georgia ppo, right?  I  have gotten so little information from people at an atlanta hospital that i'm expecting same troubles from shands/house and i need to know if i need to call blue cross before i even talk to these next two hospitals. 

And what if i call blue cross and they decide to drop me before the surgery?   i know---i'm catastrophizing..or whatever....

do i do all the calling to blue cross on my own?   does shands/house help me deal with my insurance?  are they going to be as much of a pain in the posterior as the atlanta  hospital bunch has been?  no one at the atlanta doctors office has been willing to even let me finish sentences when i have called back with these types of questions, so i've given up on the ones in atlanta.  i know there are some good ones in atl, but so far my initial contact with shands/house has been much smoother and cooperative and friendlier than what i've encountered in atlanta.

Do I ask for the BAHA up front?   how do i know what type of baha to get?

And physical therapy?  i've been told that i should arrange that before the surgery...does shands help me at all or am i on my own?

i have been totally amazed at the lack of compassion, and abundance of rudeness and impatience i've met with so far.  it was obvious that at least one doctor in atlanta did NOT want me getting second/third opinions.  they are a "paperless" office but they charge $50 each time  to send medical records to another doctor for second opinions, even if the papers are sent directly/wirelessly to the other doctor after i sign a release form.

maybe i'll have these questions answered when i talk with shands/house on phone.  i hope so.  i keep coming up with things to ask, and it just seems that someone somewhere at a hospital should be available to answer some of them.  i pray  that either house or shands handles things a little differently.

i know i can count on some good input from this bunch on the forum though, so i'm going to be reading other insurance posts in here.

In the meantime i'm going out to work with the horses and/or to paddle my kayak.

tricia

[sgerrard]

My experience was that the hospital where you get treatment will contact your insurance company for pre-approval. It has to be done in a fairly official way, with diagnostic and treatment codes included, so the insurance companies will not just tell you over the phone that sure your surgery is covered.

Having said that, I found it useful to call the insurance company, and find out the name of the hopefully senior staff person who would be handling my case. There is usually someone designated when a major medical case comes up. I was able to fax copies of various medical reports to both the hospital patient coordinator and to the insurance company case manager, which helped the process move along.

I hope you find your way through the insurance maze.

Steve

[Cheryl R]

Does your policy say you have to get pre approval of the surgery?           I know each state and ins co is different.    I did not have to do any work on my own with Iowa Blue Cross.     Did not even need to get pre approval for just the AN surgery.  Now a BAHA may be different.           I was also in network.                Each of those hospitals should be able to give you more info once you have talked to them.                      You would need to call and ask your ins about how they do go about out of network and I think you would be able to do that now and would not need to give alot of details yet.               
I don't doubt that your increased dizziness is at least partly from the stress of thinking about a lot of new info over the AN.
                                                                  Cheryl R

[sgerrard]

One additional comment: acoustic neuromas are rare, and insurance companies do not handle them every day, like they do with many other types of claims. I have seen accounts on this forum that suggest that when confronted with something unfamiliar, there initial reaction is often "no" just because they aren't really sure what it is. With some persistence on your part, I think most of them come around to realize that it is a rare condition that requires specialized treatment, and will support you.

Steve

[Jim Scott]

Tricia ~

You have a lot of questions and I'm going to take a stab at responding to some of them.  I hope some of my answers will be helpful.

One question I have for anyone here on forum: is when to talk about the insurance, how to file, how to get pre-approval, etc..  Atlanta docs I've talked with have said they have "staff" to handle it, but trying to get someone to call me has not worked out really well yet.  After persistent message-leaving, I  recently found out the approximate cost of the surgery, and even that was like pulling teeth just to get an "unconfirmed" estimate.  The hospital billing office basically told me I'd have to submit the bills after surgery  and just see what the insurance co (Blue Cross PPO Georgia) would pay.  I thought the docs offices submitted things like that, and I thought they'd have more specific advice for me than what I got.

You definitely need to talk to Blue Cross.  Check your policy provisions and exceptions to see if you can find specific instructions on what is and isn't covered and what your responsibility is.

At the time of my surgery I had Blue Cross medical insurance.  My neurosurgeon simply submitted his bill to them and accepted what the insurance company paid, as he had agreed to do when I engaged his services.  His bill was a modest $28,000. for everything, including the 9-hour surgery and his assistant's (also a neurosurgeon) services.  The hospital bill amounted to $58,000. for the OR, ICU and a 4-day stay, including meds and lousy food.  Blue Cross paid it in full.  I did get a letter of approval for my surgery and subsequent hospital stay, but it came - ironically - a week after my discharge.  My total out-of-pocket costs were close to $2,000. for everything, including 2 MRI scans (one just before the surgery and one immediately afterward).  Fortunately, the hospital accepted incremental payments, as most will do.  You just have to ask.    

I'm in Georgia and Shands is Florida, House is in LA.  SO, I'm out of network for Blue Cross of Georgia PPO, right?

Very likely, yes.  

I  have gotten so little information from people at an Atlanta hospital that I'm expecting same troubles from Shands/House and I need to know if I need to call Blue Cross before i even talk to these next two hospitals.

 

I would call Blue Cross.  

And what if i call Blue Cross and they decide to drop me before the surgery?   I know---I'm catastrophizing..or whatever....

I think you just answered your own question.

Do I do all the calling to Blue Cross on my own?

 You can but it isn't mandatory, just a precaution and a way to get some guidance.  

Does Shands/House help me deal with my insurance?

Probably.  You should ask them.  

Are they going to be as much of a pain in the posterior as the Atlanta hospital bunch has been?  No one at the Atlanta doctors office has been willing to even let me finish sentences when I have called back with these types of questions, so I've given up on the ones in Atlanta.  I know there are some good ones in Atl, but so far my initial contact with Shands/House has been much smoother and cooperative and friendlier than what I've encountered in Atlanta.

I'm sorry you're having these problems.  You won't know how cooperative either facility is until you talk to them.  I've read good things about both Shands and HEI.  

Do I ask for the BAHA up front?

  Yes.

How do I know what type of BAHA to get?

 This will have to be ascertained by a doctor/audiologist.  I didn't get a BAHA and cannot offer any personal expertise in this area.  Sorry.

And physical therapy?  I've been told that I should arrange that before the surgery...does Shands help me at all or am I on my own?

Again, you'll have to ask Shands.  Many hospitals have in-house PT facilities and you can be moved to the floor where they are.  You may not need PT but planning on it is prudent.  

I have been totally amazed at the lack of compassion and abundance of rudeness and impatience I've met with so far.  It was obvious that at least one doctor in Atlanta did NOT want me getting second/third opinions.  They are a "paperless" office but they charge $50 each time to send medical records to another doctor for second opinions, even if the papers are sent directly/wirelessl to the other doctor after I sign a release form.

This is unfortunate but not as uncommon as we would like to believe.  All you can do is avoid using these doctors and or hospitals.  They obviously do not have have the patient's interest at heart.

Maybe I'll have these questions answered when I talk with Shands/House on phone.  I hope so.

I think you will, Tricia.  

I keep coming up with things to ask, and it just seems that someone somewhere at a hospital should be available to answer some of them.  I pray  that either House or Shands handles things a little differently.

May all your prayers be answered.  

Jim

[lawmama]

Tricia,

Sorry I didn't see this before.

I'm not sure about House, but Shands has handled all of my insurance.  As a matter of fact, someone from Shands called me today to confirm my surgery.  I think she said my insurance has already pre-approved my surgery.  I'm bringing 1/2 of my deductible tomorrow for pre-op and then the other half (actually will be less because I've already paid a great deal out of pocket) will be paid in a few weeks when the claims from my MRIs go through and we know how much I still owe.

Anyway, sorry to make a short story long.  I'm pretty sure no matter where you decide to go they will likely handle the billing for you.

And I was also worried that my insurance would drop me.  I'm on brand new insurance that I've only had since August.  I KNOW they hate me because what kind of person is diagnosed with a brain tumor just two months into a new policy?  Wow.  I was just waiting for them to try to deny me based on pre-existing condition or something, but how on earth would anyone predict a rare brain tumor?  LOL

Also, I was told that Shands will send PT in once I am up and walking.  I didn't have to ask for this.

Lyn

[cindyj]

Hey, Tricia!  Don't know why I missed this either when you origionally posted...

Anyway, I have BCBS of GA (PPO) and, as you know, I went to House.  I had NO trouble with insurance.  The insurance "people" at House handled everything (once I had made my decision and set a surgery date).  I never even called BCBS about it.   It was not an issue that I went out of state.  The only time it has come up, actually, was the other day when I scheduled my one year follow up MRI.  Dr. Friedman's office had to call the local MRI folks (went to Northside Forsyth) to "order" the MRI so BCBS would cover it. 

How are you doing otherwise?  Call me again anytime you'd like!

Cindy

[CHD63]

Tricia .....

You already have many good answers ..... just adding that my neurosurgeon's assistant at Duke did every bit of the insurance potential nightmare.  Her response was "you have enough to concentrate on without the hassle of insurance, let me take that worry away from you."  It sounds like Shands and House both have similar philosophies so hope you can relax about that.  Once you make your choice for place of treatment, let them handle it ..... they are both used to AN surgeries.

Best wishes.

Clarice

[leapyrtwins]

Go to the highest person you can find within your insurance company if you are going to ask about BAHA coverage.  Most BAHA requests are turned down the first time; but be persistent!  Don't let them tell you it's a hearing aid, it's not - it's a prothesis and should be coded as one. 

I'd also not even ask about coverage of the BAHA until you are sure you are going to have the implant surgery.  If your doctor is like mine (doesn't combine the AN and BAHA surgeries) there is no need to even mention it to your insurance company right now.  Of course, if you are having combined surgery that's a different story.

Whenever you request BAHA coverage, have the doc's office do it.  They are much more aware of what insurance companies need in order to approve a BAHA request.  They can also educate the insurance company on why you need one much better than you can (nothing personal - just a fact).

As for what kind of BAHA - I'm a little confused by this question.  BAHA stands for bone-anchored hearing aid and the titanium post that goes in the skull is standard - no choices there.  The device or processor (aka tiny hearing aid) is what's different.  Your doctor or audiologist should be able to suggest the one that's right for you.  Cochlear has a few different processors (Divino, Intenso, BP100) and Oticon has the Ponto Pro.  Each of them are similar, but have different features.  The processor that's best for you often depends on how good the hearing is in your "good" ear.

Jan

[OTO]

If you decide to go to House Clinic in LA, either the Doctor's assistant or the Surgery Coordinator will send you a packet of pre-surgery info.   The packet will include an estimate of the different cost.   You can work with them to pre-coordinate the insurance.   I used that information, and call my insurance company here in Hawaii.   My insurance is HMSA PPO which is an independent
licensee of Blue Cross/Blue Shield.   I just asked for a customer rep.   She checked in their computer system, and had a few questions.   I ended up asking the House coordinator to call them.   I was fully covered, and ended up only having to pay co-payments.   I think my total out-of-pocket medical expenses were about $800 (for some reason, the anesthisiologist was the most expensive)...   I also paid about $450 for 10 nights at the Seton Guest House...

[Tricia (horsekayak)]

All these helpful responses heve been wonderful, and so much better than just worrying "on my own".  It has really helped to hear various experiences and to read all the good suggestions.  I am meeting with Shands (U of FL in Gainesville, FL) and have already been told by one of their financial staffers that they handle the insurance thing...she said patients have enough to worry about without having to deal with insurance...i agree, and it was nice to hear.

[Jim Scott]

Tricia ~

Thanks for the update on your insurance hassles.  I'm very pleased to learn that the hospital (Shands @ UF) is going to field most of the insurance minutia for you, as many facilities do, thus relieving you of this sometimes frustrating burden.  My neurosurgeon's office and the hospital financial staff took care of 90% of the paperwork and documentation needed for my insurance company (Blue Cross).  All the medical bills were paid promptly and I negotiated the co-pay amounts (about $2,000., in all) with the hospital and set up a payment schedule.  We certainly don't need the worry of finances, insurance company demands for documentation and so on as we head into surgery.  I'm glad you won't have to deal with all this. 

Jim