Insurance question - surgery

[tschanel]

We are planning to have my daughter's hemangioma excised in August by Dr. Waner. We are trying to figure out exactly how much it is going to cost us out of pocket. I am on a BCBS plan.

I have been told by Dr Waner's office that there are four parts to the bill:

Surgeon's fees ($7,800)
Anesthesiology ($2000-$2500)
Hospital Costs (~$10,000)
Lab Work ($~1000)

Dr Waner and the anethesiologist are consider "out of network", so even if the procedure is covered, I know that I am going to be paying for most of it because my deductible is very high with out of network doctors.

That leaves the hospital and lab costs. I know Beth Israel does take my insurance. However, how likely is it that the insurance company will not pay the hospital costs because the procedure is considered cosmetic? Should I talk to the insurance company ahead of time?

I feel like I should know the answers to these questions, but the medical system is a mystery to me.

Thanks for your help.

[AubrieB]

Originally Posted by tschanel

We are planning to have my daughter's hemangioma excised in August by Dr. Waner. We are trying to figure out exactly how much it is going to cost us out of pocket. I am on a BCBS plan.

I have been told by Dr Waner's office that there are four parts to the bill:

Surgeon's fees ($7,800)
Anesthesiology ($2000-$2500)
Hospital Costs (~$10,000)
Lab Work ($~1000)

Dr Waner and the anethesiologist are consider "out of network", so even if the procedure is covered, I know that I am going to be paying for most of it because my deductible is very high with out of network doctors.

That leaves the hospital and lab costs. I know Beth Israel does take my insurance. However, how likely is it that the insurance company will not pay the hospital costs because the procedure is considered cosmetic? Should I talk to the insurance company ahead of time?

I feel like I should know the answers to these questions, but the medical system is a mystery to me.

Thanks for your help.

Have you gotten a case worker thru BCBS? We contacted them and got a case worker. We sent her pics and all the details of all the Drs that we had seen so far. She worked with them and now BCBS is covering all of my son's procedures, including his surgery, as in-network. I can tell you from experience that you don't need to take "no" for and answer when it comes to the insurance company.

[Rachel06]

I would really love to talk to you. BCBS is one of the hardest - but I did notice you said that they anesth is out of network. That is curious to me because your hospital is in-network. There is somethign called RAPL - that stands for radiology, anesth, path and lab - if you are at an in-network facility - these things are considered in-network. Call me or e-mail me privately and we will talk. I am more than happy to help you out - there are a few tricks - sometimes they work, sometimes they don't but they are worth a shot.

Sherri Foster
Patient Advocate
Vascular Birthmark Institute
of New York
917-703-1903

P.S. My daughter had 10 surgeries w/ Waner - and eventually we won!!

[mmarrari]

Absolutely, I would get a pre-authorization from BCBS. We have Aetna but we made sure to get everthing pre-cert before doing it. After the procedures they tried to pay at a discounted rate, but we fought and becuase we had all the pre-authorization numbers, they had to pay 100%. Even for your out-of-network services, if you can prove to them there is nobody in-network with the skills and exprience to perform your baby's surgery, you might be able to get them to pay for everything. even though he is not in any networks, in our case Aetna covered 100% of Dr. Waners fees, anethesia, hospital and labs. We paid 150$. It might be worth giving it a try. I can give your more info if you want...
Marina

[JodiS]

We are seeing Dr. Yakes in Denver for a VM almost monthly and asked for a caseworker through Blue Cross after diagnosis and referral since he is not in network. As a BSRN and MSN, she was very helpful cleared the way for the Drs to be considered preferred so we pay 10% of an agreed upon rate. Like you, we run about $20k+ per surgery.

My Washington/ Alaska Blue Cross Blue Shield used a letter of agreement with the Colorado Blue Cross and they negotiated a fee that is considered preferred. The Hospital and Anesthesia were already preferred. BCBS requires precertification, also.

Some Blue Cross plans will cover your travel too. Allegedly mine does not, but I plan to submit it at the end of the year and appeal my denial.

[tschanel]

Thanks for everyone's responses. BCBS has said that they cannot give us approval prior to the procedure...only that we can appeal if it is denied. Sounds like we need to work some more on this.

[jgoodman0814]

we had bcbs at the time of our daughters removal in cincinnati with dr azizkhan. she stayed one night too. the total preinsurance bill was 15,500. the surgeon fee was 5500, anestesia was 750, hospital room was 2000, pharmacy was 650, supplies were 3000 and a few odds and ends. if this helps at all.

[AubrieB]

Originally Posted by tschanel

Thanks for everyone's responses. BCBS has said that they cannot give us approval prior to the procedure...only that we can appeal if it is denied. Sounds like we need to work some more on this.

We got pre-approval for the laser treatments that are leading up to the surgery, as well as, the surgery itself. We talked with a case worker asn sent pics and a description and she helped us get approval for everything. We only pay the copays.

The surgery shouldn't be considered cosmetic, but reconstructive. Dr Buckmiller's nurse, Diane, explained it as "cosmetic is taking something normal and making it better, but reconstructive is taking something abnormal and making it normal". Hemangiomas aren't "normal".

[nickbar]

If you do end up needing to appeal...we have great resources for you. Sherri Foster w/ Dr. Waner's office can help you as well as Basia with VBF.

C