Getting In-Network Coverage?

[charlsie142]

Hi all,

A little background:
I recently received my third letter from my insurance company, and this time it finally said that my upper/lower surgeries are medically necessary (SUPER EXCITED!!!! ). Of course, the next week, I receive the info about paying my OS (50% to schedule appt; remaining 50% 2 weeks prior to surgery)...which was a huge bummer. I know that my insurance company (BCBS of TN) does not consider my surgeon or the hospital he performs surgery in (in NC--I'm a student living in NC for the next few years) as in-network, so that means I'll have to cover 20% of the surgery, and I don't even know how much of the hospital fees (which are unknown completely at this point).

My Question:
So, I'm still figuring out how I'm going to pay the surgeon fees upfront, and don't have a date set yet (my OD said I'm 3-4 months away), but I wanted to ask, with there being other surgeons in my area that are considered in-network and a hospital in the area in-network, do I have any options regarding obtaining in-network coverage? I know it's not looking good, but I thought I'd ask. And, my surgeon is very well-respected and comes highly recommended by persons on this message board as well as people I know who've had similar surgeries to mine, so I really do not want to go to anyone else.

Thanks in advance...hope to hear some good news (although I'm not expecting it!).

[iBorg]

Check to see if your surgeon participates in any regional networks. You might get lucky. Failing that, get to know someone at the insurance company and explain your problems and ask them what needs to be done to get your surgeon considered in-network. Be aggressive. Just sitting and hoping won't get it done.

Mike

[charlsie142]

Thanks for the tips, Mike.. I know my OS doesn't contract with any insurance companies, so I don't know if that's means he also won't be in any regional network, but I will be calling tomorrow to find out.

[iBorg]

If your sugeon doesn't contract with any insurance you very well may be out of luck. Does his practice? Also is the hospital in network? That is about a $20K bill. You may need to consider alternate locations and surgeons.

Good luck,

Mike

[at long last]

Hi, there,

I had the same issue. I was covered by BCBS in Pennsylvania, but I live in OH. I was able to get the surgery covered as medically necessary but my surgeon was out of network. I called BCBS and requested that my surgeon be covered in network. At first, they declined, but I mentioned that there were no oral surgeons within 50 miles that were in network. They at first let me know that there was one in my city but they also called this surgeon and unfortunately he did not perform the procedures that I was getting. So, after only a day of calls to BCBS, I was able to get my surgeon covered in network. Don't know if this will work for you but it's worth a try.

I haven't had surgery yet. Just got my date for December 1 (exactly a year to the day after I got braces) so I don't know how all the billing will actually turn out. The surgery is supposed to be covered 100%. I'm hoping for no insurance billing nightmares.

[iBorg]

Okay, last's revisit this. I was originally seen by a surgeon in-network in the town I live in. He said I needed the surgery but was too difficult of a case due to the severity of the required movements and my age. He referred me to another surgeon who was out of state. I'm covered by a state run insurance program for public employees. Initially they didn't want to cover a surgeon out of state. When they realized the only in state surgeon that I was referred to was further away, they did cover my surgery.

If you can document why you need the surgery performed by this surgeon or in that location, they may be more willing to make an exception.

Good luck!

Mike

[charlsie142]

Hi, there,

I had the same issue. I was covered by BCBS in Pennsylvania, but I live in OH. I was able to get the surgery covered as medically necessary but my surgeon was out of network. I called BCBS and requested that my surgeon be covered in network. At first, they declined, but I mentioned that there were no oral surgeons within 50 miles that were in network. They at first let me know that there was one in my city but they also called this surgeon and unfortunately he did not perform the procedures that I was getting. So, after only a day of calls to BCBS, I was able to get my surgeon covered in network. Don't know if this will work for you but it's worth a try.

I haven't had surgery yet. Just got my date for December 1 (exactly a year to the day after I got braces) so I don't know how all the billing will actually turn out. The surgery is supposed to be covered 100%. I'm hoping for no insurance billing nightmares.

At long last--thanks for the helpful post! I know there is one group of surgeons that are considered in-network for me, but I don't know anything about them and I really want to use the surgeon I've been consulting with. I'll try to find out what that group actually does, and hopefully, they won't perform the types of surgery I need. Congrats on having a date set (and that's amazing it was exactly a year post-braces)!! I hope your billing works out smoothly! Thank you again for some hope-I'll post what happens when I have an answer.

iBorg--thank you again for more info...I know my surgeon is really good and trained by a really well-known OS, which isn't reason enough for the insurance company, but makes me really want to stay here. In order to have it done in TN, I'd have to drive at least 2 hours to have surgery, whereas here in NC, I'll have to drive 10 minutes to the hospital...and have follow-ups as needed since I only make it to TN 2-3 times per year.

Again, I'll update this post when I have more info.

[iBorg]

Do you have family to provide care for you in NC? If so, push that as well as the closeness of location. Every little thing may help. Explain the out of pocket expenses to travel for your appointments and ask if they're able to compensate you for those. For me my insurance person was persuaded because my parents live in the town where I had surgery and they could help out with the kids.

Ask your surgeon's staff if they have an insurance specialist who can help. Also ask the surgeon's staff how much you need to pay. Finally get a list of in-patient hospitals and surgeons from BCBS. I was thrilled to find my hospital was associated with another hospital on the Kentucky-Tennessee border which was considered in-network. That one little fact made the hospital in-network.

Mike

[charlsie142]

Just wanted to update this in case it helps anyone in the future. I requested a form from my insurance company (BCBS of TN) to ask for my NC surgeon to be considered in-network. Despite living in a large city with a lot of oral surgeons (one of which I KNOW performs these surgeries and is in-network and I'm sure there are many more), I got in-network approval for the surgeon I want! I'd be happy to let anyone know what my letter said if needed.

[Chailatte]

Hey charlsie,
Who was your orthognathic surgeon? I live in NC too and I need recommendations for consults. Are there any orthodontists you highly recommend? Thanks for your time!

[charlsie142]

Send me a private message and I'll be happy to share my orthodontist's and surgeon's names with you. I highly recommend both!