Insurance tips

[kathysjourney]

Hi to all - I continue to try and decide on treatment; either surgery or radiosurgery. I read much on this site (which has been very helpful and I am going to send more questions in soon!). I must comment on this insurance discussion.

I have seen 3 "teams". All of the doctors are out of network for my Blue Cross plan. The hospitals are in network. My PCP had told me that it would be very unlikely that any specialists at this level, doing these procedures, would be "in network". She was right! Keep in mind also, that almost everyone's insurance plans have changed in the past couple of years, and NOT for the better. Had I had treatment in '09, I would have had much better coverage. Be sure you know what your plan currently covers. What was covered in December '09 may not be covered as of January '10! Call your insurance company and find out all the procedures they may require for out of network coverage. Even if you don't need referrals with your PPO plan, you may find you can apply for a "waiver exception" (or whatever your plan calls it) for better coverage for "out of network" when there is no "in network" specialist in your area. Ask, ask, ask - as you may get different answers each time you call your insurance company. Many of the people who answer the phones do not really know details like this. Try tallking to the pre-certification department or ask for a supervisor. Also see if there is a benefits coordinator at your place of employment that you can consult with.

One tip I heard from about the 5th person I spoke to at my insurance company: Even though the doctors office will schedule the treatment and they and the hospital are supposed to notify the insurance company,  be SURE to make a call to your insurance company YOURSELF at least 24 hours before treatment. This is just reassurance for YOU that the insurance company has been notified so you will not be denied coverage is someone else dropped the ball.

Those on medicare at this time probably fare the best in coverage. Medical coverage is very scary at this point in time. It is NOT what it used to be.

Then, there are the doctors. I have not met anyone I didn't like or respect. I have seen very well respected, experienced people. BUT, if you mention your concern about expenses, their faces go blank and they can't look you in the eye. They don't want to discuss it, tell you to talk to their "billing people" (who won't say much, or they tell you to call your insurance company). When you call your insurance company, they tell you they can't help you unless they know what the cost will be, and that you should call the doctor's billing office! Then the billing offices again tell you to call the insurance company!  I also love it when professionals, friends and even family  say things like: "You can't think of the expense when your health is involved".
Are they KIDDING??

Just keep asking quesitons, I guess, and hopefully all the finances will at least not be life altering shocks! As for getting any "promises" in writing from doctors regarding what they will accept payments - I doubt that will ever happen. As one candid doctor told me - the whole system is broken. We all know that, of course!

[leapyrtwins]

Great tips, Kathy.  Very good points for newbies and "oldies" still deciding on treatment.

I guess I was one of the fortunate ones.

My hospital and both my docs (neurotologist and neurosurgeon) were (and still are) in-network; only the anesthesiologist was out of network.  I ended up paying absolutely nothing for my AN surgery and my 6 day hospital stay.

I also paid nothing for my BAHA surgery 9 months after my AN surgery.  It was performed by my neurotologist at a different hospital than my AN surgery, but it was still in my network.

My insurance company also paid 100% of my BAHA device (Divino).

I thank my lucky stars - and God - daily.

Jan

[kathysjourney]

Hi Jan - thanks so much for your replies. Our Blue Cross policy isn't really bad, but our out-of-network coverage isn't wonderful, and I have found these specialists in the ny metro area don't participate with Blue Cross,(who would've known that?) even though most hospitals do.
Kathy

[lawmama]

Good tips!!!  I'm still fighting with my insurance company (Aetna) after my December surgery.  They are denying all claims and say they are doing a "pre-existing condition review."  I can somewhat understand this because I switched insurance providers somewhat recently, but considering I had never before had an MRI or a CT scan nor been to a doctor complaining of any of the symptoms that might have led to such a diagnosis, I don't see how they will get around paying this.  Who would ever guess they have a brain tumor?  Anyway, it is good advice to keep up with your paperwork and anticipate there might be a little aggravation getting them to pay.  I'm not too worried because I'm in the right and I know a lot of lawyers.  Haha.

Lyn

[kathysjourney]

Wow Lyn, what aggravation to deal with after all you have been through. I'm sure it will all come out in your favor once they can find no evidence that you knew about your condition, but you don't need the stress of fighting with them. Yes, these insurance companies are tough these days. Let me know when they give in - I know they will. Just think about being well. I'll see what happens with my own insurance once I finally make up my mind which treatment to go for! That's a long story for me. All the best - Kathy

[lawmama]

Kathy,

Like I said, I am not too worried because I know there is no way they will be able to deny the claim in the end.

I wish you the best of luck with your own insurance company fight.  Just keep plugging away and keep paperwork and notes about everything (of course, I'm sure you already know that).  Good luck and keep us updated about your decision and about the outcome. 

Lyn

[oksandra]

Thanks for the tips.  I'm trying to figure out the insurance thing now.  It would be so nice if this were not something we did not have to worry about at the same time as worrying about treatment options, our families, and our long term health.

[Jim Scott]

Kathy ~

Your tips on handling medical insurance issues are appreciated. 

I was fortunate that my wife is a former insurance claims manager (auto and home, not medical) and handled all of the business with Blue Cross, our insurer at the time of my surgery (in 2006).  Both my doctor and hospital were in-network and there wasn't any problem with the bills.  Once I'd met the 'out-of-pocket' deductible ($2,500.) Blue Cross paid at 100% for everything.  I didn't really have to pay the $2,500. 'out-of-pocket' but since I owed it, Blue Cross considered it as if I had already spent the money.  Actually, I simply set up a 12-month payment schedule ($208. per month) with the hospital.  My neurosurgeon (a secular saint) said he didn't want me worrying about money and that he would accept whatever payment the insurance company offered.  He was true to his word.  Blue Cross paid him $23,000. for the almost 9-hour surgery and his assistant, also a neurosurgeon, was paid a whopping $5,000. for her work in the OR.  I never received a bill from the doctor, and his fee included quite a few follow-up visits.  The hospital bill was about $60,000, not counting the cost of MRI scans (at approximately $2,500. each...and I had 3 within 3 months).  AN surgery doesn't come cheaply.

I consider myself blessed in many ways for how well my AN experience went and wish every AN patient could have a similar experience. 

Jim