help! My PS is out of network and I need a prophy

Annabella58

Hi all,

I've been on here forever, I am ready to go get that prophy on the remaining girl....my PS is out of network and I have no coverage for him.  I can't switch insurances since I am "grandfathered" in mine and I buy it solo (Anthem).  Rock and a hard place. 

I'll be 5 years out end of 2012.  Til then I am stuck.  Any advice?  I can try to Aetna, but broker feels I will be rejected as not 5 years, and had bc twice. 

You'd think a prophy would be viewed as a very good thing, in this case, no?

There is a great PS in network, but I have been told by my PS not to switch horses in m ain stream.  This is seconded by my BS.  Anyone know if this is valid?

THanks, gals.

cinnamonsmiles

I don't have any experience with reconstruction, but I do have experience with switching drs. during treatment and have read about women who have switched during treatment for one reason or another. I switched, however, because of incompetence, rudeness, etc.

If it were me, and I trusted the other dr., felt comfortable that he/she could do a good job, I would switch. They would review my records, check me out and I would check them out during the appt as well (including post op pictures).

It may not be your first choice, and it really sucks getting a wrench thrown in your plans. But if you can't get the other ps,  and can't get any other insurance, you either live as is with no ps, or go for it, guess it boils down to how bad you want reconstruction after a pmx.

I truly wish you the best in this hard decision on an already hard journey. 

As my pain counselor is trying to teach me, he says don't think it of as all that bad, just think of it as a pain in the ass and go on. So easy to say, so hard to do.

mrsnjband

You might try to appeal to your insurance to consider this ps as part of your group since you had the doctor before..  It's always worth a try.  

Why wouldn't they think a phrophy is a good thing? It's your choice. They have to pay, it's a federal law. For both the mastectomy & the reconstruction.  My insurance took their sweet time in paying for both the orginal mastectomies & then my delayed (3 years) reconstruction but they paid.

I could have had the reconstruction sooner but I was afraid of the pain.  I started getting infecdtions on the BC side so I finally decided to do bi-lateral DIEP.  Very happy with the results & have very little pain now.  Not near as bad as I thought it would be.  Actually I am in less now than before!

Hopint you can get this worked out. NJ 

peggy_j

Wow, that sucks, but I'm confused. Your PS says not to switch horses midstream--does that mean he use to be in-network for your medical insurance and now he's not??? Regardless, can he make it easy for you to stay with him? i.e. take your insurance and charge only the network-negotiated rate? Some docs write-off losses. Ask if he can do something like that for you. 

I hear your point but I'd also hate the idea of paying the full rack-rate for an out-of-network surgeon esp. when there is a good one in network. What will be the diff. in your out of pocket costs? Thousands (or tens of thousands?) of dollars. Seems like a lot. 

BTW, I hear ya about being stuck on the insurance situation. I read that if you think you're going to get rejected on your insurance that it's better not to apply (i.e. in a NYTimes article, one person said that the first question on my applications is "have you ever been rejected for health insurance?" One rejection now might mean an extra red flag going forward) So it might be better to at least wait until 5 yr NED to give it a try. Good luck. I hate all this insurance BS. 

Chickadee

Why shouldn't you "change" at this point if the in network PS is, in your words, great? Did your previous PS and BS have clinical reasons not to use the in network PS? That just sounds a little bit like a professional thing rather than a danger to you.



Why not meet with the in network PS and interview him or her. See how they respond to your concern about changing PS because of your insurance issue.

Annabella58

Wow!  This is great, thank you all so very much!

I did not even think of that red flag, but of course, it would be one.  I will NOT apply for new.

They did not have clinical reasons to not use the in network PS as far as I know, only that they both said that my original guy had "been in there and knows what was done"  (extensive lat flap stuff) but it is not the same breast, so???  I thought the same; perhaps it was more of Pride of Ownership thing than a danger to me as well.

Good advice on meeting with the in network guy.  I did, the first time out, have the same insurance, ended up paying o of pocket 5K and got a lot of free work also.  He was the most wonderful person,very very kind so I have gone ahead and asked for him to see if he could accept what they would pay IF they paid yet again.  It would be a big loss for him and he's become a big PS star, so don't think so, but worth trying.

We did appeal with many letters to Anthem to get him citing he had not finished me (no nipple), that he did the work before, that my onc, GP, BS all wanted him.  they turned me down flat (pun intended) bec. they have an in network guy.

So....I think I will NOT apply to Aetna, and I will see what my original PS says, if he turns me down, then I shall go interview the new guy.

Thank you all so very, very much.  Much appreciated.

The in network PS is supposed to be fantastic as well.  The $ difference will be twenty four thousand dollars.  I need a reduce and lift, then heal 3 months, then the TEs and prophy, then exchange, then nipples.  The original is looking bad also, it is sagging, has developed ripples, dents, etc, tho MRI showed no rupture.  The skin is bad from rads in 2001 so it is a different kettle of fish.  Then tatoos for the nipples.  It's alot.

peggy_j

The $ difference will be twenty four thousand dollars.

Wow, that's a lot, esp. when the in-network guy is supposed to be fantastic as well.  Since it's a diff. breast, seems like it would be ok to have another surgeon.  I liked the suggestion to at least meet with the in-network guy. I agree it's probably better to stick a surgeon you know and like but (IMO) that's a lot of dough that could be spent better elsewhere. (time off, nice vacation etc). Good luck. 

Fearless_One

You would rather spend 24K than find an  in-network surgeon?   I really think you should reconsider.    

Annabella58

No, no ladies you misunderstand me...I never said that I'd want to do that. (spend 24K), only that that is what the guy I prefer would cost.

This is what a reduce and lift, prophylactic mtxmy, exchange, nipples, tatoos, costs around here.  It's normal.  We are on par with Beverly Hills for cost of living. (SW CT).

That said, it's not what any insurance would cover.  Nowhere near.  Hence some PS's will strike a deal where they will take what insurance would have paid, IF they paid.  This is what happened to me the first time out.

The in network PS may have the same fees and most likely does.  Since it is Anthem, they pay almost ridiculously low fee scale.  Many PSs in this area simply do not participate in any plans at all.

I need to have a consult with the in network guy and see what he can/will do.  I've heard good things.

It's just that I do love the original PS so much....but 24K out of pocket, unless we won a lottery, isn't going to happen in any way at all.