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BriellesMum 03-26-2009 07:22 PM

HELP - Confused by Insurance! What is or isn't covered?? Frustrated
Well, now that Brielle is 9mths old old weighs 23lbs we've decided to go ahead and have the surgery and have Dr Waner perform it. Her H has grown (mostly outward) and there is little involution. We live in Delaware but feel Dr Waner is the best Dr to perform the surgery. We've scheduled her surgery for May 20th.

I've emailed Dr Waner's office (Sonja) and discussed insurance issues. They have been great but I still don't understand were we stand and what will or will not be covered.

I'm hoping someone can help me understand. Perhaps someone who has had same issues, same insurance, etc. Any help is appreciated!

Here are the details as I know them:

- We have Blue Cross Blue Shield Personal Choice Insurance (a PPO).

- In our plan Dr Waner is considered an out-of-network Doctor.

- Beth Israel Hospital is considered In-network

- Not sure if the ins will cover costs of Anesthiseologist.

- Sonja is waiting to hear back from Insurance Co to see if they will make an exception and accept Dr Waner as an In-network Doctor

Honestly, I am confused by all the info. I still don't understand how much we will have to pay out. How do we know if the insurance company will consider this an approved (and not elective) procedure? If this is an approved procedure and Dr Waner is considered out-of-network, how much will be covered (we are 80/20)

If the ins co denies it and we go ahead and pay for surgery, what are the odds the ins co will reimburse us if we appeal?

Any help would be greatly appreciated.

missy 03-26-2009 10:34 PM

Write to our insurance expert:

and see if she can explain it!!


CarrieChris 03-29-2009 08:11 PM

A predetermination does not guarantee that payment will be paid in full. We too have Highmark PPO and I will outline our experience with payment below:

Laser treatment- $7700 for Dr. Charge, Insurance co. paid $2200. This is what they felt was reasonable and customary. Balance $5500 due to doctor since he's out of network.

Surgery- $45,700 doctor charge, Insurance paid $8,900, this is what they feel is reasonable and customary charge for this procedure. Balance $36,000(approx) to doctor since he's out of network.

Each and every time the hospital was covered 100%, as well as the anesthesia, less our deductible of course.

So even though your insurance pays 80/20 that is not 80% of the entire bill, that is 80% of what the insurance company feels is reasonable and customary. Reasonable and customary is an average cost for the same procedure that is done by multiple doctors across the US.

nickbar 03-30-2009 09:38 PM

This is the frustrating part, insurance co. hold us the key.... they decide after the care on what they will pay unless you are able to get a pre-approval and that depends on your policy/co. do talk with Basia our insurance expert! What you can do is appeal to the insurance co., with what is considered customary... to have them pay at a higher rate, which I mentioned would be proving this surgery could not be done by another doctor for the rate they are willing to pay out. Sonja should be able to tell you how much Dr. Waner's bill will be... your insurance co. should be able to tell Sonja what they will pay based on the billing codes that would be billed. I know this is frustrating. I would also talk directly to your insurance co. and ask what your options are on having pre-authorization, an idea of what will be covered.


LuckyOne.40 05-12-2009 12:27 AM

In my twenties, I had facial reconstruction surgery using tissue expansion and I had an individual policy with GHI. Like you, the hospital was included in my plan, but the doctor was not. To answer your question about anesthesia, it should be billed separately and will be administered by a participating doctor, due to his affiliation with the hospital. Prior to my surgery, the insurance carrier agreed this was reconstructive and they would pay benefits per the contract. The night prior to admission to have the tissue expander put in, I received a call saying there was a change and it would no longer be covered. Since there was nothing that would stop me from having the surgery, I told the representative to send me the decision in writing and had the surgery the next day. Eventually, I contacted my state insurance board and they did the rest for me. When all was said and done, not only did they cover me, but they paid the entire cost of both surgeries for the tissue expander and several surgeries for “touch ups”. After dropping them, I switched to Blue Cross Blue Shield and have had no problems with coverage.

Here are a few things you need to know. First and foremost, you must use “birth defect” and “reconstructive surgery” when addressing insurance companies. Secondly, most denials can be eliminated by checking with the doctor’s office to be sure the billing codes they are submitting to the insurance company are for reconstructive procedures. Third, the insurance companies use a “schedule of allowance” to determine benefit amounts. Since conditions such as these are not common, most times there is no schedule for such procedures and you need to ask for a “case manager”. Lastly, most insurance plans have a catastrophic allowance”, which means that once you pay out a pre-determined amount per your contract, the rest of the heath care for that year is free.

If you need any information, please feel free to contact me and good luck

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