TriCare denied skin & nipple sparing mastectomy!!!

Tricare (Humana - Tricare South Region) paid for my skin/nip sparing BMX in Nov. 2010.  Did your providers not get pre-approval from Tricare before they went ahead with your surgery?  Who reassured you that Tricare would cover everything, and did you sign documents that you would assume responsibility for what insurance would not cover?  Is Tricare's reason for denial the procedure itself - or its applicability to your diagnosis?

I'm not well versed in insurance issues, but wouldn't Beckydar's surgeon's office and/or the hospital bear some, if not all, of the responsibility if he performed surgery on her and neglected to get the necessary approval -- especially if she was told it was covered?!  No one in their right mind would consent to an uncovered $63,000 expense if it wasn't an emergency surgery, nor would I think most doctors or hospitals in this day and age would perform a surgery without being sure the patient had insurance coverage, or detailing the cost and requesting a significant down payment.

It sounds to me like the surgeon's office or hospital office is at fault (whichever one assured you it would be covered), but you probably need to get an attorney who specializes in this sort of problem involved to sort it out for you.    

So sorry you're dealing with this mess, but it sounds like your surgeon's office and/or the hospital dropped the ball on this one.  Deanna 

Write your own letter and make sure you send a copy of that letter to your Senator or Congressman (cc it at the bottom of the letter)!  If you keep plugging away at them there is a good chance that they will pay... But you must act now and you have to be forceful...  By the way, insurance companies are known for totally disgarding anything you say to them that is NOT in writing..  Make sure you keep the request for appeal within their alloted time frame (found on your insurance package paperwork)... if it is already outside their time frame be prepared to justify why it is late - (example - you thought it had already been accepted and paid, you would have expected a notification from the insurance compay, you were told on the phone that it would be covered etc..)  My insurance turned me down on everything except the most minimum of services but I had them reverse things after I was taken care of and they did eventually pay for everything - including some items I would have expected them to balk at...  I think it was the cc to my Congressman that did  the trick in my case.  Good luck and keep trying to push it back on them for as long as the hospital will allow..

Beckydar 

Cinnimon's advice is good advice.  I would also like to suggest that when you speak to anyone over the phone, get their name.  Always ask and write it down.  May as well ask their position with the company too.

Getting all these details leaves the company little room to hide. 

Part of the issue here is the specific insurance plan the OP has.  This is military insurance and it is very specific in what they cover, and how coverage is handled.  If the OP has the same plan that I have all prodecures done by anyone other than the PCP require an initial referral from that PCP.  The referral is submitted and the procedure is approved in advance.  She should have received a copy of the approved referral in the mail (separate ones for her breast surgeon, her plastic surgeon, and the hospital) prior to the procedure being performed. It was the responsibility of the surgeon's staff to obtain the referral for coverage, and it is their bad that this was not done, particularly if they reassured her it had been taken care of.  I find it surprising that these docs would go ahead and operate if it was not clear where their reimbursement was coming from.  I have had a lot of surgery, as you can see by my sig line - there were approvals in place for every one or they would not have operated, and I made sure I had the written referrals in hand prior to showing up for surgery.  I even had an emergency surgery and the plastic surgeon's staff got a stat referral prior to the surgery - they had about 30 minutes to do it.  I also had skin/nip sparing and my left breast was "prophy" so my surgery was for the same reasons as the OP and Tricare paid.  My Mammaprint was denied, on the basis that Tricare considers this "experimental" even though it has FDA approval.  The breast surgeon's office did not get the approval for it, although the biopsy was approved.  I did not sign anything saying I would pay if insurance denied it, so Agendia and my BS ate that bill.  Tricare had paid $61 in handling costs only, so I called Agendia and asked for an Assignment of Benefits form which states that they will accept what insurance pays and write off the rest, I filled it out and faxed it back so all they got was that $61.  Tricare also will not pay for BRCA testing under any circumstances as of 2011.  I have diagnosed LE and they pay for my PT but will not pay for my sleeves.  

I had a breast reduction and they denied me 2 times. Finally got it approved after a year. I had my breast reduction in 08/2010 on 10/20/2010 my PS called me into his office and told me the biopsy of my tissue showed DCIS stage 3 I took it like a champ while I was in his office and called my husband right away as he was in training at the time to head off to Afghanistan. While I did the tomaxafin treatment and was not liking how it mad me feel. By 01/2011 I had the same procedure you did. It was the fastest referral I had gotten and I didn't have to pay a dime. Now my husband is retired and tricare/humana works different. I'm in Texas and no surgeon what's to fix my abdominal wall that is week and hurts everyday so I got a referral to see the original PS in California to fix this and see if they can do the revision of my breast. Since my 1st surgery I have lost over 20 pounds and my breast look flat. I had the tram flap surgery. I'm just hoping tricare/humana covers it or that I only have to pay the 25%. Good luck in getting it approved. Idk why it wasn't approved in the first place.