Good Insurance News (For Once!!)

Message

#1 Post by **chicago29** » Fri Jul 10, 2009 11:55 am

I had to post this just to let people know that if you are willing to research and ask questions, sometimes the insurance companies make decisions in your benefit.

I just found out this week that my insurance company paid my surgeon the FULL AMOUNT from my surgery back in February. I was absolutely shocked when I saw this. My expectation was they would pay about 30 to 40% of the total fee from my first surgery, so to learn they paid it in full and that I get my deposit back is awesome news...

The reason I got it paid at a higher level is I demanded an "out of network" exception. There are no "in network" oral surgeons within 100 miles of me. Now, nobody at my company or at my insurance company told me about this...I learned about it from reading other people's stories and researching on my own.

It took a few phone calls to my company's benefits administrator and the insurance carrier, but finally they agreed to pay my claim at the "in network" rate, which is of course higher than the "out of network" rate. That was great news at the time, but I still figured it would be well below the total billed amount since "in network" rates are still only at the contractual usual and customary rate...And we likely all know that almost every oral surgeon out there charges well above that usual and customary rate.

So, my advice to any of you fighting the insurance company...KEEP FIGHTING!!!! There are positive outcomes that can occur, so NEVER get discouraged even if you keep hearing "No". Research, and get the benefits you are entitled to.

-Chicago29

#2 Post by **AFLeadDog** » Fri Jul 10, 2009 12:51 pm

Awesome!!!! Drinks on Chicago...Hopping in the car now, be there in 6 days

#3 Post by **HokieTay** » Fri Jul 10, 2009 9:17 pm

Chicago, can you provide me any insight on this? Or anyone else Tonight, I just saw what my insurance company is paying for my out of network surgeon and I am shocked, saddened, and depressed beyond all belief at what they're "covering" or paying toward it. It is absolutely not what I expected and I guess it's my fault b/c I misread things as I'd be responsible for 30% of the billed amount when really I am responsible for 30% of the allowed amount or something. I dunno, it's all so confusing. Anyhow, I planned on paying about $4k for this surgery (plus braces cost), but now it looks like I will be responsible for about $13k. I am beside myself thinking about having this much debt. The surgeon's office has $7100 right now and they will get what Blue Cross is covering, but I still owe them more and I can't even begin to think about paying it.
I just don't know what to do b/c I went to 3 different surgeons before making my decision... 2 out of network, and one in network. The one in network was just bad and I did not feel comfortable. There are others in network within my region, but I couldn't afford to keep paying $200-$400 in consultation fees.

Oh, and the worsttttt part is my surgeon was "in network" up until 2 months before my surgery. When I had my consult and started the process they were in network. Then they dropped on April 16th.

#4 Post by **blindboarder2008** » Fri Jul 10, 2009 9:19 pm

ssweet that awesome chicago!!!!!!! it never hurts to do a little research and to keep calling into the insurance company!!

hahah drinks sounds good! lol

#5 Post by **chicago29** » Sat Jul 11, 2009 6:37 am

If anybody wants to come to Chicagoland, I'm more than happy to buy you a drink!!

HokieTay...Your story really saddens me. First of all, for your OS to suddenly go out of network is very bothersome. I had a talk with an OS that I didn't go with for various reasons, and he explained to me how many OS's are getting out of insurance plans. The reason is exactly as you highlight...Their payable amounts are so low that nobody wants to have to be bound by such limiting coverage amounts. I don't mean to suggest that a surgeon should get away with outrageous fees, but I do understand all the skill that goes into this, and what most insurance plans cover is really an insult to the surgeon. Thus, they are abandoning them and unfortunately that burdens us patients.

I have to admit that I'm beyond lucky here...At no point did my carrier say that they would pay my claim in full. In fact, they made it a point several times to say they would reimburse only at the "usual and customary rate". I asked my treatment coordinator what that usually was for my insurance plan, and she stated that in the end I would be lucky for them to pay 40% of the billed amount. It very well may be some sort of clerical mistake as to why they paid the full amount, but I assure you this is one mistake I'm not asking about!!!!

My only advice would be to ask for an out of network exception, if there are no in network oral surgeons in your area. Blue Cross has MANY "dead zones" where there are no oral surgeons in network, and they will often grant an exception if you are more than 50 miles away from an in network provider. Again, this is likely only to get them to pay at the "in network" rate, which is still below the total billed amount.

Honestly, that is all I requested...I wish I knew how my claim got paid in full because if I knew of some way to make it happen, I'd tell everybody on here.

HokieTay...Best of luck to you and I hope you are healing well. It sucks that you have to deal with this so soon after going through such a procedure...and I hope that things work out for you.

-Chicago29

#6 Post by **HokieTay** » Sat Jul 11, 2009 9:18 am

Yeah, I guess I am going to argue that he was in network until April 16th and my surgery was June 15th, but I started the process in March. I found him through BCBS provider directory!!
I don't think I can get the out of network exception b/c I am in the Washington DC area and there are lots of doctors in network. However, I saw one and didn't like him. The first surgeon I saw was out of network and charged me a $250 consult fee I never got back. I decided not to go to them because they were out of network!! I looked into going to get more opinions, but I could not afford to keep paying the $250-$400 consultation fees.
I can't do anything until Monday as everyone is closed.

#7 Post by **iBorg** » Sun Jul 12, 2009 9:08 pm

This is a problem that cam up for me on July 10. I'm being left with a $6500 bill that I did not expect. My plan administrators changed and I was told that I'd be fully covered when the local OS referred me to an out of state doctor due to my age and the difficulty of my case. I was stunned that because OSs are under a different medical billing code, they can bill the patient for what the insurance doesn't cover.

Any suggestions would be appreciated.

Mike

#8 Post by **chicago29** » Mon Jul 13, 2009 2:03 pm

iBorg,

This sounds like a bad situation if you don't have anything in writing. I'm not quite clear from your post what exactly occurred, but it sounds like your benefits administrator changed, and you were referred to another OS.

Did your insurance know of the OS change? I would assume they did, since the OS has to be the one that files the Predetermination of Benefits.

I originally had my first OS submit my predetermination, and I ended up going with another surgeon in the same practice. I STILL had to have the new surgeon file the predetermination. I'm hoping you had to do the same, otherwise I'm afraid your carrier is likely only to pay for the original OS that filed the paperwork.

This is terrible that this has happened to you...Carriers are not really up front about it, but if you go with an out of network provider or an "unauthorized" provider, they sock the patient with the fees that are above the negotiated schedule (reasonable and customary charges).

Anyway, in your case I hope you have some sort of paperwork or audit trail. That's probably what you'll need to get any sort of satisfactory resolution to this.

Best of Luck,
Chicago29

#9 Post by **chicago29** » Mon Jul 13, 2009 2:05 pm

By the way, for anybody else that may pursue the "out of network exception" route, I forgot to add to BE SURE TO GET IT IN WRITING.

I was just going to take their verbal agreement since they called me back in January to tell me the exception had been granted. My Treatment Coordinator at my OS's office recommended I get the agreement in writing both for my file and for my personal files. I highly recommend anybody else do the same...

#10 Post by **Esoteric** » Mon Jul 13, 2009 2:34 pm

Congrats. My Ins. paid for my whole surgeon fees as well which I thought they were going to pay about 60% of. It's kind of a nice surprise.

#11 Post by **iBorg** » Mon Jul 13, 2009 8:14 pm

The OS my ortho referred me to referred me to another OS out of state due to the complexity of my case. The plan administrator that I had at the time did approve of me going out of state to an in-network provider. The issue will be that the dental school views themselves as separate from the hospital although they are all part of the same university. I was told that with the approval I would get full in state coverage.

I talked with my ortho's staff today and was advised to keep all my paper work and not say anything until I receive a bill from the dental college. At that time ask for documentation from me agreeing to pay the non covered amount. After they either provided that evidence or not, go from there.

As if I didn't have enough to worry about concerning my numbness!

Mike

#12 Post by **ladyjenie** » Tue Jul 14, 2009 9:29 pm

I did not have such good luck with Aetna. They did not offer an in-network provider within my area. My out-of-network OS sent in a pre-estimate letter with diagnosis codes and charges for each procedure being done. Aetna greatly reduced the fees based on Reasonable & Customary. I appealed and got nowhere. I contacted the HR department of my husband's company and involved them. They turned it back over to Aetna, why, because they are self-insured and don't pay unless fees are drastically reduced saving the company money. In my case the OS would not negotiate nor does he accept insurance.
By all means make notes of all insurance personnel you talk with, jot down date, time, rep's name & I.D. # & their direct phone number. Remember, there are my Kathy's and Debbie's in any large company so it's important to I.D. your contact person so you can go back to them if there's a problem.
I did get a 2nd opinion from an in-network OS although I had to drive further to see him. He gave me a different diagnosis and I may not need TJR to help my problem. More or less he said the first doc I saw did TJR on people that could have had lesser orthognatic surgery or jaw advancement. Make informed decisions before selecting your surgeon and do not be mislead.