Out of Network Appeal?

GreenEyes81

Has anyone been able to appeal our of network providers and been covered as In Network? I live in Montana....I do not have much options for reconstruction other than implants. I can got to Huntsman/University of Utah for DIEP....but stacked or more intense procedures I am not sure about. No other location under my insurance is covered.

I would love to go to Center for Restorative Breast Surgery in New Orleans. It seems the surgery would be shorter, recovery shorter ect. I was going to have DIEP in March...thus got the "don't lose weight" comment. I had to cancel and am looking at October at the soonest. I do NOT want to keep the extra weight that long....so it seems if I lost weight maybe a Stack flap would work for me....if so, then I don't have anyone in Montana, Idaho or Utah to do the procedure, thus I need to either change insurance or find a way to get a out of network location covered as in network.

Any one expirence this? Have suggestions? Am I correct on losing weight then a stack would work? I am looking at unilateral recon.

Lula73

greeneyes81-I did get my insurance to cover out of network as in network rates and at NOLA. You need to apply for an out of area exception. Call your insurance and just state the bare minimum facts: 1) I need breast recon from BC, 2) there are no in network docs anywhere near me that does the type of recon I’ve chosen (DIEP or stacked flap), 3) what steps do I need to take to ask for an out of network doctor to be covered to perform the recon? That’s it. Don’t volunteer any info about Utah or any other center. If they ask where you are needing to go or what doctor/group, only state the one you want to go to (NOLA). Make sure to include St Charles Surgical Hospital and any other providers that will be out of network (ie anesthesiologist, radiologist, etc) for you to have it done at NOLA. My insurance took the application over the the phone. They did do a preferred provider search for DIEP within 50 miles of my home and of course came back with 0. It took a couple weeks to get the approval. Then Vickie at the center can reverify the amount insurance will pay and what your part would be. It’s helpful if you get the contact name of who name of who VIckie needs to speak with once it’s approved to ensure the reimbursement amounts given are the in network rates.

Falconer

Hi GreenEyes,
What type of insurance do you have? I have Anthem BCBS and I had to go out of network for my stacked DIEP. Well even though I have a letter saying that the surgery was approved the insurance company denied the claim. I was billed $77,000+ because the doctor's office never finished negotiating a price before my surgery. I grieved it, twice, and was denied both times. Finally, a colleague gave me the number for our insurance broker who runs the whole PPO. The claim was settled the day after he called on my behalf.

What I was advised by the insurance company for my stage two- if I can travel to my doctor's home base where he is now an in network provider in CT that will save me the headache of trying to make sure the "in for out" claim is made. If not, it is imperative that all the t's are crossed and the i's are dotted should he come to my local hospital to perform the surgery (which he does as well, out of network).

Ugh insurance.

Good luck!

GreenEyes81

Thank you both! I have Montain Health Coop, I couldn't find anything in fine print so wasn't sure. I have hope!

Lula73

greeneyes81-is your insurance through an employer?

Falconer

greeneyes, I do recommend my doctor- Greenspun- who is in NY and CT. Since his office does have experience in dealing with the "in for out" process they may be able to advise you on how to proceed for the stacked DIEP. If you are considering traveling to NOLA would you travel anywhere?

GreenEyes81

My insurance is through Affoordable Care Act.

Falconer-I will keep that in mind if I have any problems with NOLA. Thank you!

queen_k0302

I'm also having a problem with BLUE CROSS BLUE SHIELD arkansas open exchange. I live in Arkansas. I really want to go to NOLA. I have a history of getting bad infections and complications with every procedure I have had. I just done feel the doctors in my network are skilled enough for my situation.

(I'm also diagnosed OCD, the fear of unsymmetrical breast is one of my worst fears)

Falconer

Queen, if you can find a doctor whose office is willing to negotiate they can usually take care of the insurance piece for you. It's such an unfair situation. When buying a home or car I do the brokering. When finding a doctor someone else is doing that with my insurance company and I have no idea about the cost. its not transparent at all. And very frustrating. As if we need more to worry about when we have cancer to fight!