Out of network with plastic surgeon

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mazy123
mazy123 Member Posts: 38
edited August 2015 in Employment, Insurance, and Other Financial Issues

Hi, I had my BMX on May 21st. I went in network with breast surgeon, but out of network with plastic surgeon who did alloderm and put in TE during that May 21st surgery.

Got explanation of benefits for BMX and ended up paying $1844(to breast surgeon) towards my $2000 in network deductible for that part of surgery.

Well, got explanation of benefits from insurance company for plastic surgeon part of surgery and they are only paying $1800 to him and I am paying $1400 towards my $4000 deductible for out of network. That seems laughably ridiculous to me. Does that sound right at all?

I have my exchange surgery in less than two weeks. The insurance company won't pre authorize it because it is outpatient and they started a policy two months ago that they won't pre authorize outpatient surgeries. So, I have no idea what they will cover or won't cover with second surgery.

This is all making me very nervous. Thought I would check on these boards to see if there is any advice. I did read a post about contacting the state commissioner's office. I thought we had good insurance until all of this.

Thanks,

Mazy


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  • vlnrph
    vlnrph Member Posts: 1,632
    edited August 2015

    Kayb is on target with her approach: get whatever estimate you can in writing beforehand then ask for an adjustment after if something unexpected arises. For instance, people have been surprised by anesthesiologist bills due to the practice group not being in network but they're the only ones who staff that hospital!

    I am also aware of the idea that out-patient procedures do not require prior authorization. Record the names of whoever tells you this and make a note of when you spoke with them.

    Read the appeal information the insurance company provides and take action promptly according to their time limits or you may lose the right to have your case review.

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  • mazy123
    mazy123 Member Posts: 38
    edited August 2015

    Kayb and vinrph,


    Thanks so much for all the helpful information. Feeling energized to start looking into this tomorrow. Thanks for taking the time to share a this information!

    Mazy

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  • edwards750
    edwards750 Member Posts: 3,761
    edited August 2015

    kayb is right on. You pay dearly for going somewhere out of network but you can ask them to write off the difference. We have BC/BS. They advised us to do that recently when my DH got bitten by our dogs in the middle of a big fight. The closest hospital was out of network. In retrospect he probably could have made it to the network hospital but he was bleeding. Anyway we are going to appeal to the hospital.

    We have a big deductible too like 5k. When I was DX we buzz sawed through that deductible in 2 months. Thankfully they paid 100% after that that included radiation which was about 35k.

    Good luck. Don't take no for an answer.

    Diane




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  • kareenie
    kareenie Member Posts: 339
    edited August 2015

    Another approach would be to ask for an out of network GAP EXCEPTION. This means there is no one in your network or in local geographic area who can do what this provider is doing. Ask your insurance how to go about it.

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