Denied out of network for recon

I'm sorry to hear this.  I have an insurance plan (not an HMO) that provides no out-of-network coverage.  Of course my PS is out-of-network.  His insurance person got the denial (which was somewhat expected).  The PS then did a peer-to-peer and I was approved for in-network.  And, I live in a major city with a create medical center (Houston).  They did not make me use an in-network physician.  I'm doing a BMX with immediate DIEP (right side will be prophalactic).  The insruance person at the PS's office did tell me that there were some ins cos that she wouldn't even try to work with.

A friend (whose husband is a physician) suggested that you also go to your HR person to help you advocate (if your ins is through an employer) because ultimately, you're the consumer but HR is the one with the bargaining power.

 Good luck!

Sorry you're going through this but since out-of-network charges can be huge you're wise to deal with this now. In addition to your HR person, you might want to see if there's a consumer health-insurance advocate you can call (there's one in CA; I found it on the *.gov site and the person I spoke to was surprisingly helpful and informative). I agree w/ Deanna. It's not right for them to dictate the terms of your care. That said, I always thought that NY had some of the best cancer docs in the country, so I wonder if there are options to do it in-state with just one procedure???

pandazankar, I haven't been able to find the specific info' I wanted to find for you, although I'm still looking. In the meantime, you might want to search for posts by BCO member Dutchy.  She had a big hassle with getting a referral to UCLA for DIEP recon, but eventually won her case through a Medical Review Board appeal. 

I know you feel like you don't have any fight in you at the moment, but all it's going to take is figuring out the proper procedure and steps, and following through.  You don't have to do it today or tomorrow.  Take your time, gather as much info' as you can, and at that point it probably won't be that big a deal to file an appeal.  Hang in there, and don't be discouraged!  These decisions are often determined by clerks or computers in the first go-round, and often get reversed on appeal.    Deanna

This conversation reminded me of a couple things I heard/read:

1) my DDS's receptionist said that when she went to training for one of the dental insurance companies, one piece of advice they got is that if a claim gets rejected, just submitted again because a different person will open the envelope and process it. Obviously, that doesn't help with BC, but even the insurance companies are acknowledging that the decision varies by the person handling that claim. arg.

2) one book I read last year (maybe "Planet Cancer") had a chaper titled something like "How I gamed the insurance company.")  Her story, if I remember correctly, was bad because she quit her job and HR didn't properly process the COBRA form and so she had no coverage. Regardless, she had great strategies for working the system. She would call, ask some questions, then call back, get someone else, and use the info she learned to act like she'd already gotten a partial approval (or something). It was a ballsy move but this woman was desperate and it worked. Just an FYI in case this is inspiring.

You may also want to reach out to Nordy... she had her surgery in NOLA, where they also do simultaneous SGAP... and I think it was Nordy who had to fight the insurance company... Post this at NOLA in SEPTEMBER thread and I am sure someone will chime in... There was one woman who got her HR person to change her plan to a PPO, even after she had made her elections for the year.

I am sorry you are going through all this... it just shouldn't be this hard... I did see your post on the NOLA thread... and read a post on some other thread... for what its worth, if a doctor's office is unsure if the doctor does the procedure, I would not go there. You want a doctor who does it often. Dr Dellacroce in NOLA does the SGAP all the time... there are lots of us GAP girls... There are only three surgeons there and they team operate. Did you reach out to Nordy?

I'm not surprised that you can't switch insurance until Nov; the big companies have their rules. But are there any other consumer health insurance advocates who can help w/ your out-of-network issue? i.e. this morning I saw that the LA Times even has one.  In Calif. there is one via the *.gov website.  Is there one for your state? Have you considered contacting the cancer patients' advocacy groups? (I've seen them mentioned here, somewhere...) 

I think you should circulate a petition and have US all sign it... it is absolutely absurd that they find their decisions logical. Perhaps present them with medical abstracts, documenting the dangers of multiple anesthesia for one and all the other reasons... they are sounding a bit like my MO who thinks I could have stayed local and gotten great recon... he simply glosses over the fact that I didn't want Tram or implants, or lat flap... MEN.

I'm in the same boat. I have no out of network just out of pocket. The PS is of course not in network. Can you tell me what peer to peer is? Any advice would be appreciated..