BCBS PPO - Out of network question

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imatthew
imatthew Member Posts: 206
edited June 2014 in Employment, Insurance, and Other Financial Issues

Hi All,

My wife is having stage 2 DIEP reconstruction with a doctor that is out of network for BCBS.  We simply paid the deductible for her initial surgery, and the surgeon accepted both that, and the 60% of remaining fees that BCBS covers for out-of-network, as payment.

I'm wondering if I can appeal to see if they will reimburse at the in-network rate, there is only one other surgeon within 50 miles that does this procedure.   

Has anyone ever appealed to BCBS to cover at an in-network rate?  If so, did you have any success?

Thanks in advance! 

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  • Del11
    Del11 Member Posts: 944
    edited May 2011

    I did this for SGAP, but since she's already had one surgery with the doctor without that exception I think it may be harder to get at this point.  They also may stick on the fact that one other surgeon in the area does the surgery.  I got the PPO exception prior to the first surgery, not as an appeal, so I'm not sure it's possible to do on appeal.

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  • Thriver
    Thriver Member Posts: 10
    edited May 2011

    Hi,

    I am a long term survivor of advanced breast cancer.  I've been advocating and appealing HMO and PPO denials and referrals for cancer patients for about 11 years now.  I haven't had a case exactly like yours though.  However, it is always worth it to appeal.  The fact that there is only one other doctor within 50 miles will help your appeal.  Even if you don't win at the first level, you might be able to appeal to a higher organization in your state if denied.  What state are you in?  I've helped folks nationwide.  I am in California.  I'd be glad to help.

    Thriver

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  • imatthew
    imatthew Member Posts: 206
    edited May 2011

    thanks Thriver, we're in Va, but our provider is based in IL.  I'll give them a call and see what happens!

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  • AnneW
    AnneW Member Posts: 4,050
    edited May 2011

    They may not do it retrospectively, but you may get a break on her Stage 2. Good luck with this. Working with appeals takes patience and time. Lots of it, usually.

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  • edwards750
    edwards750 Member Posts: 3,761
    edited May 2011

    Agree with Thriver..all they can do is say no. I will be interested in knowing how your appeal comes out. I have a appeals case with them now. I had the Oncotype test done with approval of BCBS. Genomic Lab does the test and they checked with BCBS. They called me and verified my insurance would pay for the test. I had the test done; thankfully had good results and then get the poison pen letter from BCBS saying they WONT pay for the test...I called Genomic and they said they had already sent my case to them for appeal. When I talked to my BS and ONC I told them I would not have the test done if insurance didnt pay for it because it is a $4000+ test. Really pricey....anyway havent heard anything on the appeal but suffice to say I am NOT paying for the test. Genomic Lab did not seem too surprised they refused to pay because they said it was like pulling teeth to get them to pay for anything. As far as I am concerned the battle as to who pays is between Genomic and BCBS...The lady with Genomic was really nice and didnt seem too concerned....Good luck...diane

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  • gsolis
    gsolis Member Posts: 2
    edited June 2011

    My surgery is scheduled for next Tuesday (6/14) and I just got a call that my insurance is not accepting the out of network plastic surgeon referral, even though there is no one witin 100 miles that does the DIEP flap surgery.  Now I have to wait and see what happens.  What else can I do in such short notice?

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  • suzanneinphoenix
    suzanneinphoenix Member Posts: 208
    edited June 2011

    Hi, gsolis.......I would ask who they would suggest you go see for this procedure.  You are allowed by law to have they type of recon you want.  Ask them if they are going to pay your expenses for travel, hotel, etc....just to see an in-network doc!  I hope you get things worked out......

    Suzanne

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  • Sue-61
    Sue-61 Member Posts: 599
    edited June 2011

    Hi, All, I used to be a nurse casemanager for a health insurance company. They would approve something OON (out of network) to pay as IN NETWORK if there was no suitable doctor within a certain number of miles......maybe 25. I retired a few years ago so I really don't know how even my own insurance works. BUT I did find that the person who shouted the loudest seemed to get the issues/denials resolved earlier. And some insurance companies do have an emergency appeal dept.

    I would suggest you all call your insurance company and request a nurse casemanager. They can speed things along. I used to do it all the time. Even when I got my diagnosis, the first thing I did was request a casemanager from the Oncology team as I did cardiac stuff and knew nothing about breast cancer. Of course a lot of members thought I could just approve things one a whim but that isn't the case. (someone was not very fond of  me for not putting in babysitting, no kidding...........but there was no benefit for it anyway.)

    Good luck. Sue

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  • gsolis
    gsolis Member Posts: 2
    edited June 2011

    Thanks for the advice.  I am going to call and ask for a caseworker.  Me sitting here and worrying about being denied isn't going to resolve anything.  Really appreciate it.

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  • cycle-path
    cycle-path Member Posts: 1,502
    edited June 2011

    I think Sue's advice is excellent. I have one small suggestion -- tell the BCBS staff person that you are willing to go to the more distant provider as long as they're willing to pay for an overnight hospital stay, because you won't be able to make a two-hour drive immediately after your procedure. You never know, it might work.

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