Hi, Sue,
I had surgery at SBI and here is my insurance story. When I realized I needed to do something about my AN regrowth (I was W&W for 9 years before that), I had HMO. There were 3 top neurosurgeons available through this HMO in NYC area. After talking to them, I realized that the situation was very difficult and I needed special expertise. I decided to go to House which is out of state and my HMO obviously does not cover. Meanwhile, I was researching SBI and all I could find about endoscopic AN removal. So, either way, I needed to travel to CA for surgery.
At the end of 2006, I changed to Aetna PPO during the open enrollment period. The surgery was now considered out of network (covered at 70% ), the hospital where Dr. Sh operates and the House - in network, covered at 100%. The insurance does not reimburse for travel, lodging and food.
I decided on SBI, my neurologist got a precertification for surgery from insurance company and I had my surgery on June 27, 2007. A few days after coming home, there was a huge article in a local newspaper about Aetna and how it was short-changing consumers. There were two issues: 1) the "reasonable and customary" rate for determination of out of network benefits was laughably low and 2) patient was stuck paying for out-of-network physicians when they had no choice in in-network hospitals, like anesthesiologist, radiologist, pathologist, etc.
Before long, the bills started arriving and they were for thousands of dollars from people I have never even seen. Dealing with insurance company took many unpleasant months and it was a full time job. The bottom line was that I paid only $20K that Dr. Sh demanded from a patient if insurance does not pay the entire amount as well as travel costs to CA. This is just too scary to mention the amount I would have to pay had I not battled the insurance company. The expenses for surgery as well as travel for it, by the way, are considered incurred medical expenses for tax purposes. I wrote them off taxes that year.
The amount the insurance paid plus my $20K was still a lot less than what Dr. Sh charges for surgery but he accepted that amount as a full payment and sent me a letter. I was lucky I had the money to pay, otherwise the cheapest way to have surgery would have been through HMO doctors which did not have the necessary expertise. So, just because you are changing to PPO from HMO, don't assume that everything is covered. The insurance company has a myriad way to deny you benefits. They posted huge profits for last year, didn't they?
Good luck!
Eve
