Insurance and Reconstruction

I had the same issue and was able to use the out of network doctor but had to pay higher co-pays. My understanding is that insurances companies must pay for reconstruction by law. Our doctors are such an integral part of our care that you should go with the one you feel most comfortable with.  And fyi, the doctor likely does not even have a clue about the insurance issue since she has an office manager to handle such things.

Wishing you the best.....

I had my BX with expanders placed on April 12, 2012. The breast surgeon was covered and we received authorization for BX and breast surgeon, also for reconstruction and plastic surgeon, including the hospital. A month later I noticed they denied the PS claim, I called, they resubmitted it. Again they denied and resubmitted it the next month. Two days before my final surgery, the PS called me and cancelled my surgery to replace the expanders with permanent implants. They hadn't payed him and wouldn't authorize the surgery. ROCKED MY WORLD! When i called i was told, the doctor needs to send in something saying why this was medically necessary. REALLY! They said i went out of network, funny because they don't have an in network provider in my city. I had to get the HR people at my husbands work involved. After an extra 6 weeks they finally approved the surgery and the PS. If I could find a lawyer to sue them I would, expanders are not very comfortable not to mention the emotional stress they caused me. The law states that if they cover mastectomy they must cover reconstruction. It seems they have found loop holes in the law! If you go a year without them giving approval and paying, you are then responsible.

Peggy Have you talked to your MO about getting tested? Mine had told me that they have a form they fill out that kind of tells if we "qualify" based on how old you/other family members were when you got the cancer, etc. I had mother, many aunts, cousins, grandmother etc that had cancer and they took their ages and mine when I got cancer. Anyway when I had mine done, the MO said that Myriad was basically the only game in the states because of the patent. They drew my blood and sent it and told me that if I were going to have to pay anymore than $400 Myriad would call me to tell me how much it would be and see if I was willing to pay for it. My insurance ended up covering it but would not cover the 3rd part of the test, called the Bart test, because the others came back negative so I didn't have that part done. While it is a relif that I didn't test positive for the 1st 2 parts I still feel as does my MO that genetics are still at play some how since so many family members of mine had it. He advised me to have daughters, granddaughters etc seek care at the breast cancer center at an earlier age as if I was positive (I don't have any daughters or granddaughters so that so far is not a worry). Because other cancers like ovarian, gastric etc come into play with Brac 1&2 I was also asked if I had any 1st degree relatives that had any of those when qualifying for the testing.  You may want to contact your MO and ask about it if you haven't already and then Myriad as they deal with various insurance companies and may be able to give you more of the guidelines and costs. They do have various payment plans as well if insurance doesn't cover it. http://www.myriad.com/patients/learn-about-genetic-testing/genetic-testing-faqs/    Good luck I know you want the best for your daughter and future generations and it gets so frustrating.

Hmmm -- I just now see that Maria probably made her decision long ago (since she posted in Nov)... but just in case some new-bie comes looking -- I'll go ahead and post.

My first choice for BMX with immediate DIEP reconstruction was Denver. I loved the general surgeon, and liked the plastic surgeons just fine ... but then (just like Maria) I found out they were not in my insurance  network (BCBS) AND their surgery schedule didn't have room for me to get in until after the first of the year... so they suggested I do the procedure as a 2-stage -- BMX with TEs in November followed by the DIEP in January. 

That seems way-nuts to me -- to choose 2 major surgeries and recovery times over just one... and adding the whole step of TEs seemed crazy ...

So I called around to other breast recon centers and found one (with long-standing experience and excellent reputation) that not only WAS in my insurance network, but could do all-in-one surgery right away! (PRMA in San Antonio)

It really doesn't matter where on the map your surgery takes place. You go stay there in the hospital, then check into a hotel for a week so they can keep an eye on you. It perhaps added $1000 to my expenses -- and that was money SO well spent when compared to TWO surgeries instead of one, and being in pain twice as long through the recoveries!

** Your insurance company may accept your chosen type of recon -- just not every doc who performs it. That was certainly my experience.

Just like anything else -- if you can keep your head and comparison shop -- choose the BEST docs that can offer you exactly what you want -- then location does not matter. **The one caveat is that you will want to drive instead of fly -- because post surgery you will probably be missing lymph nodes, and need to be careful about pressure changes (like flying) to protect against lymph-edema.

(Same warning about comparison shopping applies to your meds -- I am now on hormone therapy -- one pharmacy wanted $1300 for a 90-day supply -- another $636, and Costco was only $18 !!!!!)

Peggy -- I agree with 2 fried eggs -- you may be able to get your onc to ask for the test, even if you don't quite fit the profile. I very badly wanted that info to help me decide whether I should choose BMX over the UMX. It is a helpful piece of the puzzle... so you feel you have all the info you need to make your best choices. Knowing that your onc won't/can't prescribe the test SHOULD be reassuring -- they certainly know the predictors ... but seeing it in writing does bring a new sense of surety...

Best of luck to all here -- I am now 8 weeks post-BMX/DIEP recon -- and can say that I am doing GREAT. In fact -- 2012 (although full of surprises) was actually I think my happiest year EVER. Amazing what epiphanies BC can bring with it... our bodies are incredible machines, and we are lucky to be living in today's world of science-fiction-fact... despite the unknowns. Maybe in 5 years we will have the cure. But in the meantime, we have what we have, and we have so much more than 50 years ago!

Linda

Good point. We always figured we would go right back to San Antonio -- if necessary due to complications.

Luckily that hasn't been necessary -- as (knock-on-wood) I have had no complications. 

DIEP is not available anywhere in my state. (NM)

Therefore, to get DIEP -- I was forced to travel anyway. Denver would have been 5 hours, San Antonio was 12 hours drive. 

I am so thankful though that I was able to think outside-the-box -- because DIEP immediate recon has been a WONDERFUL choice for me. If I had listened only to my onc/surgeon -- and what was available 'locally' -- my options would not have included anything more than TE's and implants -- available in my state -- but STILL 5 hours drive away in Albuquerque. I researched all that -- had two meetings with a PS I liked there, and consulted with my lumpectomy surgeon about doing the UMX... but for me -- the DIEP was my best choice, and I am thrilled with the results.

Another consideration for me was that to have the weekly inflations of the TEs would have meant a 10-hour-round-trip for me each week...

Anyway -- Special K's point is a good one. Of course we all HOPE we will be the lucky ones without complications, but you never can tell.

Linda

Maria,  someone from the PS's  office the night before the surgery told me that his surgery costs $123, 530.00 and if the insurance did not pay he would agree to take $20,000 as full payment from me! I was so desperate, I agreed!  Actually, at that moment, I would have agreed to give him my first born, and I only have one child! LOL!

We were working on a time crunch!  I met with the PS on the 23rd. of July and within one week I had the surgery!

Not too much time to weigh all my options!

Mena

itsjustme,we were not looking for just a PS, we were looking for a PS  in my net- work who does the DIEP .  So if she had done what your BS did, the only one she could have found in my net-work who would have qualified could NOT have done the Reconstruction at the same time as the mastectomy!  I think you are much braver than I am, because you would have picked the BMX and then found the PS!  If I had to make that  choice, I think I would have just had the BMX and NO reconstruction!

If the insurance does not pay the claim, I can handle the $20,000, but I would never have been to handle being cut up again after healing!

But that is me!   We are all different and that is what makes all of us special! We each have our unique way of thinking!

If this has been covered already, please let me know:  I had BMX (with an in-network provider) on November 23, and immediate reconstruction (with an out of network plastic surgeon, but one who was highly recommended, and has worked with the breast surgeon for years).  I just got the explanation of benefit from my insurance company.  They are paying 60% of "usual and customary", which I know is typical, but their estimate of "usual and customary" is crazy!  After the deductible, and the 60%, they ultimately paid the plastic surgeon a grand total of about $275.  The office said that was the lowest payment they have seen yet.  My question is:  what is my most effective way to appeal the low payment?  Does anyone have experience with the insurance commission (I'm in NJ)?  I'm not going down without a fight!   Shoshana

Ginger, I'm not being altruistic.  I am being balance billed for the rest of the many thousands that the PS charges.

No, just the PS professional fee.  I am assuming the hospital fee will be covered adequately, as it is an in-network facility.  I already called the insurance company, complained that the "customary and reasonable" fee is unrealistic (to put it mildly) and am now working on an appeal letter.  I'm going to get a more realistic estimate of average fees from the Board of Medical Examiners, PS, and will use that information as well.  I also spoke with the Insurance Commissioner, so that if/when I'm not happy with the response from the insurance company I can go further.  Wish me luck!  (So this is why I usually stay within network!)

Ablydec...have you spoken with your PS office, to see if they'll handle the appeal for you?  One way to show that their reasonable and customary is anything but, would be if you knew what the going rate in your area was - and your PS office is probably well aware of what that would be, and has probably written hundreds of those letters for people. 

Boy, I can't believe these charges! My PS did immed direct to implant reconstuction for about $1300. His bill only. The BSs mast bill was about the same! Wow, this out of network stuff seems fraudulent--far more than the value of the work done.

The actual implant was in the $20,000. range which seemed high.

Good luck to you in your appeals.

My PS billed $12,000 for one side, $4,000 for the other (total 16K) but is willing to take 11,500 if he gets it right away.