Has anyone here appealed the allowable amount with Anthem?

[double jawbreaker]

I just received word back from Anthem of Blue Cross regarding the "allowable amount" they are willing to pay for my surgery with Dr. Gunson. Anthem is willing to pay $645 of the corrective jaw surgery with Dr. Gunson. Has anyone here had experience with appealing an allowable amount? Thanks for any input on the matter.

[I love my teeth]

yikes! But since they "approved" the surgery, that means that the hospital costs, ect will be covered per your policy, right??

So, your only costs after your deductible and copays should be the rest of Gunson's surgical fees, right? Still an ouch, as I know their fees are high.

Sorry, what's next for you? appeal the allowable?
good luck! so stressful, when are you supposed to be surgery ready?

[Marisama]

Wow, that really is a joke! I am waiting to hear back on how much Aetna will pay for my surgery with Gunson. Good luck with everything!

[double jawbreaker]

I Love My Teeth, I think 70% of the hospital fees will be covered. Believe me I'm grateful for that. As for the next step...I'm not sure if its even possible to appeal an allowable amount, but its worth looking into.

RYANvaughn I hope your insurance results are better than mine. I've heard good things about Aetna. Good luck. Post if you hear anything.

[jul]

I appealed to Anthem. The only grounds that they reconsidered for my claim was that there were no contracted or in network surgeons to do the surgery. They decided my surgery was necessary but the contracted payment amount was less than $1,000.00. That's probably why there are no contracted surgeons.

[double jawbreaker]

Jul, thanks for responding to my post. No wonder there are zero contracted surgeons. Have you already had the surgery? If so, who? If you haven't what are you planning to do?

[nineeyes]

I appealed my insurance, Blue Shield CA. I had a different surgeon and the cost was around $13k. I was only able to get BSCA to pay up to their maximum contracted amount which was around $3k, initially they only offered a portion based on their out of network benefits. They didn't budge on paying more when I filed another appeal unfortunately. Luckily they did cover all the hospital and anesthesiologist costs.

[double jawbreaker]

nineeyes, was your surgeon in the BSCA network? When you say the maximum contracted amount was $3000...is that based on a percentage of the total surgery amount of $13,000, or would the maximum still be $3000 even if the surgery cost $40,000. Thanks for sharing your experience.

[HokieTay]

From my experience, BCBS/Carefirst/Anthem is THE WORST. I had an AWFUL experience with them and footed a lot more of the bill than I thought I'd have to. My advice is to absolutely not go out of network with them. The allowable amount is set in stone. It does not matter if the surgeon charges $10k or $100k unless, of course they're in network. I appealed and appealed, fought with them to no end and got nowhere. And they actually screwed up and processed the claim out of a BCBS area when it should have been processed out of Carefirst. So they took the money back that they originally paid and paid out of Carefirst, but it was EVEN less. Basically they paid about $2700 on a $14,400 bill. That was only the surgeons fees. So I still had anesthesiologist, hospital, and braces. Luckily, the anesthesiologist and hospital were in network, but with the 70/30 breakdown I was still hit with about a $3400 hospital/anesthesiologist bill. Needless to say I paid a lot out of pocket, but I am happy to say I am about to make the last payment on the hospital bill and then it is ALL paid off. Not too bad considering my surgery was only about 22 months ago. I put about $7200 of the surgeon's fee on an interest free credit card and paid it off in a year! I also left BCBS and will NEVER go back to them again. I have Cigna now and they have been great the past 1.5 years.

[nineeyes]

Pretty much what Hokietay said. I had to appeal to go up from a few hundred to the allowable amount which was around $3k. I didnt have much success with any followup letters and phone calls to cover the remaining surgeon fees of around $10k. My hospital and anesthesiologist were in network so I was okay on that end.

Just to add, there were no in-network surgeons with in a few hundred miles of me in LA - which I brought up in my appeal, though I still wasn't able to get past their allowable amounts.

[cvn]

Anthem paid about 20% I think out of the surgeon's fees for my redo with Arnett, but we're still appealing them refusing to pay for any part of the assistant surgeon's fees, and it's been almost a year since my surgery. We're on our second appeal. I could use that money - I wish they'd pay!

[double jawbreaker]

Hookie Tay, congrats on paying everything off in 22 months. Luckily Goletta Hospital is in BC/Anthem's network. Like you I will have to pay 30% of the hospitalization fees. I'm especially annoyed with the letter I received from Anthem two months ago informing me about my 25% premium increase. I can't wait to change when this is all over. Hookie Tay, did you have any trouble switching insurance after the surgery (pre existing jaw condition and all)?

Nineyes, I live relatively close to LA (OC). Since there is no "in-network" surgeon for two hundred miles from us, you would think we have a legit case to appeal. I'm disappointed to hear that had no bearing on their decision. What kind of option is this?

cvn, I forgot all about the assistant surgeon fees. I'll have to look that up on my payment breakdown. Wow, enduring surgery a second time...Blue Cross should comp your surgery and give you the "Biggest Trooper award" for the burden of doing it twice. Do you have a blog? I'm trying to follow as many Arnett/Gunson cases I can.

[cvn]

It's actually my 3rd surgery. Good times (not really).

I don't have a blog. It's not really my style. I'm happy to answer any questions. I wish we had gone to Arnett for my first surgeries, but that was 15 years ago and we didn't know any better. I consider the money well spent, especially considering the extended monitoring that they're still doing for me.

[double jawbreaker]

cvn, I appreciate the invitation to answer questions. You've had three times the experience to share. Have you posted much about the original surgeries you had on this board? What were the issues with your previous surgeries? I'm a bit concerned about resorption, but I understand the surgeon's technique dictates the possibility of this occurrence.

I have to admit after meeting Dr. Gunson and reading the feedback from several Arnett/Gunson patients, I feel confident in Gunson's expertise.

[HokieTay]

Hookie Tay, congrats on paying everything off in 22 months. Luckily Goletta Hospital is in BC/Anthem's network. Like you I will have to pay 30% of the hospitalization fees. I'm especially annoyed with the letter I received from Anthem two months ago informing me about my 25% premium increase. I can't wait to change when this is all over. Hookie Tay, did you have any trouble switching insurance after the surgery (pre existing jaw condition and all)?


Thanks. Well, I work for the federal govt so our insurance (thank god) does not carry pre existing condition clauses. I also have a wide choice of plans. I have not had a problem with Cigna covering anything. My premiums are extremly low compared to what many people and it's the same for everyone in the govt. ie John Smith who has no problems and me, who has had jaw surgery and stuff pay the same premium every month.