Insurance says no to out of state surgeons

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AndiBaby
AndiBaby Member Posts: 2
edited June 2014 in Employment, Insurance, and Other Financial Issues

Can anyone offer some advice? A friend's mom has been diagnosed with breast cancer. She lives in Connecticut. She met with different surgical teams and has decided to go with Drs. Ashikari and Salzberg in Westchester NY b/c they will do nipple-sparing and importantly, the immediate insertion of implants during the mastectomy with no anticipated additional surgeries. It's important b/c she is a stroke risk and on coumadin, so the less procedures she has to deal with the better. She has Medicare and supplemental insurance policy; they are telling her they won't approve her going out of state. They are telling her there are other surgeons in CT who do mastectomy this way, which is actually not accurate (now she has to call all of them to verify that it's not accurate and/or they don't have much experience with it). My friend is battling the insurance company and I advised her to contact the CT insurance commissioner as well. Any other advice, resources, experiences? Her surgery was supposed to be today, now pushed back to January, and she has cancer...!!! Thanks so much for any help.

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  • lago
    lago Member Posts: 17,186
    edited December 2010

    I can't really offer much help but I do hear from my parents that Medicare is so screwed up. Half the time the do get it wrong.

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  • lauri
    lauri Member Posts: 267
    edited December 2010

    This probably won't be popular, but ...has she considered NOT doing reconstruction ?  Simpler surgery, fewer side effects.  I was 62 when diagnosed, and my feeling was that people don't really SEE older women, so why bother ?  Getting rid of the cancer and moving on to the rest of the treatment was what I wanted to do.  If she would like to hear about non-reconstruction, there's a whole topic or she could PM me.

    Sounds like the in-state-only problem is not with Medicare but with the supplemental insurance carrier -- and without knowing the provisions and restrictions of her policy, we can't say.  But the state insurance commissioner is a good place to start.

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  • Fearless_One
    Fearless_One Member Posts: 3,300
    edited January 2011

    One step with nip sparing  is a common procedure.   I find it odd that she says no surgeon in the state of CT can do it.   I have private insurance and it wouldn't cover an out of state surgeon - this is not only a medicare issue.  

    Recon with no insurance costs about 20K.   So she has 3 options.

    A CT surgeon

    Pay out of pocket 20K

    Have no recon.

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  • MaryNY
    MaryNY Member Posts: 1,584
    edited January 2011

    AndiBaby: I live in Westchester but went with a surgeon in CT. However in my case I had a lumpectomy although I was originally scheduled for a mastectomy with a Westchester-based surgeon. I went for two second opinions, one with a BS at Sloan-Kettering and the second was the the BS in CT who finally did the surgery. I was very happy with my final decision.

    My insurance now will no longer cover going to see doctors out of state, so my situation is like the reverse of your friend's mom.

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  • AndiBaby
    AndiBaby Member Posts: 2
    edited January 2011

    Thanks so much for all of your responses. So I'm pretty sure it will work out b/c now that it's year end, she can switch insurance to a PPO option and get covered for the surgical team she really wants. Her surgery has been delayed but I think it will be this week. Tough stuff, but I think it will be OK for her. thanks again!

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  • glanter
    glanter Member Posts: 78
    edited January 2011

    Standard Medicare does not have a process for pre-certification or pre-authorization so the "no to out of state" has to be coming from elsewhere. 

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