Paying for saline implant replacements with bcbsnj

kaylaartist

I had bi lat mastectomy and reconstruction in spring 2004.  My implant on the right has a slow leak.  The excellent dr. who did the original work at RMJ in NJ is no longer in network and the office has told me that they NEVER get approval brom horizon bcbs HMO to do out of network at in network rates.  Then there's the issue of the hospital outpatient deductible of $2500. (IN network)  There seems to be only one other dr. IN network with experience at this in NJ within 50 miles.  The original dr. has agreed to see me for a consult for free, but I know I cannot afford either of these drs.  Yes, I'm not broke, but that's a lot of money for me and I am self employed.  Any savings is to cover my slow periods.  And I went into great debt with the original diagnosis years ago.

Are there any other options?  Any information on the WHCRA seems to be about the original work and financial assistance anywhere is only for those who are poor.  Any advice would be appreciated.  There is no family willing to help.

itsjustme10

I hate to be the bearer of bad news, but if your doctor isn't on your HMO, then depending on how restrictive your contract is, chances are that you have two choices - iether use the in-network physician or pay for the doctor of your choice yourself, and deal with all the ancillary bills that come along with that choice. 

We all made decisions when choosing a health plan - do you give up freedom of choice for lower monthly premiums - and sometimes it doesn't work out to your favor.  So, your health plan will probably not want to play ball with you, because there were other options - indemnity plans or PPO's, that would have covered this, but been more expensive each month. 

The fact that you are guaranteed treatment under the WHCRA doesn't mean you are guaranteed the doctor of your choice if he is not part of the medical plan you selected.  Your carrier isn't refusing to replace the implant - they're just telling you that you need to work with the restrictions in the contract you purchased, and providing you with a doctor who can do that for you. 

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