Surgery next --- now the insurance game

[A's Mommy]

Hi friends,

I have a regional insurance company. Not one person in network takes care of PNE. I have (I think) made successful appeals/claims/whatever you call it thus far to cover treatment I have had in Phoenix. We had to write all these letters and submit some medical dictated reports, etc, through my PCP to my insurance's medical management department. They authorized us going out-of-network. Now, I have a few worries.

1) Does authorization to go "out-of-network" automatically mean they will pay all costs? I'm thinking not.... but the lady doing all this at my PCP's office didn't know either. I guess it's too late now, because I've already had some treatment out there (Botox).
2) Now that I'm going to have surgery, which from what I've read on TIPNA is a major cost, I want to be absolutely SURE SURE SURE that everything will be covered by my insurance. How do I go about this? I'm so confused. Do I call my medical management division of my insurance directly? It seems like the well-meaning lady at my PCP's office is as clueless as I am with this whole insurance out of network thing.
3) Where can I find the latest scientific articles?

Thanks in advance,

A's Mommy

[Celeste]

Out of network means they don't pay as much as in network. But hospitals and doctors settle for less in some cases. I think your only negotiating power is up front, before surgery. Is there any way for you to have a consult with the hospital finance department in AZ to see if they have any advice for you now that you have a surgery date?

FWIW, many people went into surgery having their insurance say it was covered, only to have it denied afterwards. This is a common insurance tactic, BTW. Some people just paid what insurance did not, and others fell into a loophole where they weren't liable for it because the insurance had authorized it.

Also, it's easier to get the preliminary appointments covered out of state than it is surgery, from what I have seen on the forums.

[Celeste]

I also wonder if you might get a referral on a Patient Advocate in your area. This past winter I spoke with somebody on the forum who said that hiring one was just a key thing for her, to help get somebody who really knew how to make problems like yours get taken care of. It kind of makes sense that if somebody deals with insurance companies all the time, they would know how to get these things done. I think it's probably harder for the rest of us who just don't even know where to begin.

[Karyn]

Hi AM,

I also wonder if you might get a referral on a Patient Advocate in your area.

That's an excellent suggestion! Instead of going through your PCP, I would contact your insurance company DIRECTLY.
"Out of network" coverage usually means that you pay a percentage. It varies from insurance company to insurance company. I would also think you'd need a pre-authorization prior to surgery. Ususally, the surgeons office gets that but for your own peace of mind, please contact your insurance provider, so there are no unpleasant surprises.
Warm regards,
Karyn

[A's Mommy]

I spoke with my insurance company regarding my last trip to AZ. We obtained prior auth to go out of network.... sent in all my medical records, wrote numerous letters, etc. I double checked with them today and asked them if my entire Botox procedure was 100% covered and they said yes, because the hospital negotiated for a lower rate with my insurance or vice versa. Something like that, I'm not sure. Regardless, I asked them if we should go through the same steps to get prior auth for the surgery. They said yes, have your PCP's office write a letter of medical necessity, send in everything, blah blah blah. But what Celeste said scares me. I don't want to go in "thinking" that I'm 100% covered then get stuck with huge bills. How do I prevent this? This is the part I'm not understanding. If they tell me I have a prior auth number and everything, how can I be sure? What's the "gold standard" for complete peace of mind?

[Celeste]

I don't want to go in "thinking" that I'm 100% covered then get stuck with huge bills. How do I prevent this? This is the part I'm not understanding. If they tell me I have a prior auth number and everything, how can I be sure? What's the "gold standard" for complete peace of mind?

I'm not really sure you can have that complete peace of mind in today's insurance climate. There is no law that prevents them from reneging. I think there should be, but that 's neither here nor there. Get everything in writing in case you need to use it later. I know LesM actually sued his insurance company for failure to pay for his son's surgery. I don't know if anybody in Hibner's office can help, but maybe there is somebody at the hospital they can direct you to if you ask. They court this business from travelers, and somebody has to have an answer for you.

[pomegranate]

A'sMommy,

LesM emailed me a template and other files for appealing to an insurance company to cover surgery. You might be able to use some of the documents. PM me your email address, and I'll send you everything he sent me. It's a bit old, but you might find it useful. I haven't looked through much of it, as I'm currently not pursuing that route.

I also have a regional insurance company--such a drag, huh?

Lauren

[Amanda]

I cant help you with US Insurance applications, however Les did manage eventually to succeed in getting funding for his son Aaron.
The main thing I believe is that it does take a huge amount of perseverance and tolerance to get claims through....so hang in and stick with it.

[Celeste]

I cant help you with US Insurance applications, however Les did manage eventually to succeed in getting funding for his son Aaron.
The main thing I believe is that it does take a huge amount of perseverance and tolerance to get claims through....so hang in and stick with it.

He paid for surgery out of pocket. He took the money he was going to use to pay for his older daughter's college, paid for the surgery, and took out a loan for her tuition and expenses. Then he sued because what they did was wrong and he wanted them to be accountable, not just to him but to the next person. I never found out how the court case ended. He was such a mensch. I've met such good people through this shared misfortune (and it continues). Life's funny that way.

[Quilter 2]

Hello to all;
Since I'm going to be needing this info in the near future, I need to understand what all these abbrevaions mean. Please tell me what PLP, FWIW and BTW means.
Sorry for my computer ignorance;
Doreen