Anyone beside me having issues with the Cleveland Clinic? Cancelling my surgery

[KarenK]

My ins. denied coverage. CC did an urgent peer-to-peer appeal. CC called when the urgent appeal was to be completed, said it was denied and ins. co. won’t respond again until 11/2, surgery is 10/24. So we’re in the 2nd level of appeals. CC said my case was submitted to the powers that be and they would go ahead and do surgery and deal with the ins. on the backend. CC also said that they were going to except what the ins. pays and I only need to pay $275 and I wouldn’t be liable for anything else. Said they were a non-profit and this is what we do to assist when needed.

It didn’t seem right, I was very doubtful. I talked to the drs. office the next day about the surgery being off. The assistant had the managing NP call stating the same thing about the limited charges to me.

So thing are moving along and I start to hear little tidbits of info. from various people that conflict with what I’ve been told regarding coverage and that the urgent appeal was never filed.

I’m supposed to fly to CC this Sat. Yesterday I received 14 requests for info for pre-op tests and these requests include payments I’m to make before testing. There’s also a doc. to sign that says I will be 100% liable if ins. denies coverage or any and all amounts that ins. doesn’t pay. This was not what I was told.

I just received a partial estimate for surgery, $278,840, that doesn’t include the anesthesiologist, any other drs. or personal involved.

I asked for additional estimates. I received a partial again of $21,000 for some of the pre-op. On the hospital stay I was told, “we don’t do estimates on that because we don’t know what the charges will be”. Huh, CC doesn’t know how much they charge for rooms in their own hospitals? I did see on their site that ICU and cardiac rooms are $6,200 a day. 5 days would be another $32,000 plus I would assume much greater charges for all that goes along with that.

Today 2 different people read to me the original agreement that I mentioned at the start. When I asked for a copy, one kept saying no, and the other said it was illegal! When did it become illegal to document the terms of an agreement between parties?!

Known charges are $330,000, my guesstimate is charges may be $450,000. (10 yrs ago I had a craniotomy at the Mayo Clinic for a leaking brain aneurysm that was $100,000. That’s a 35% increase every year to get to $450,000.)

Kinda feels like bait and switch. So, at this late date I now have no protection if the ins. continues to deny coverage. The CC could decide not to proceed with challenging some or all of the denials. Then it all falls on me.

The CC didn’t follow through on the ins. appeal in the past… they may not in the future when they have another funding source…me. Lost my trust in the CC, I’m going to cancel my surgery.

 

[dick0236]

CC also said that they were going to except what the ins. pays and I only need to pay $275 and I wouldn’t be liable for anything else. Said they were a non-profit and this is what we do to assist when needed.

Get it in writing!

PS: Your bio states the surgery seems pretty standard......aortic valve and aneurism. I would think a local "in network" Arkansas doctor could perform the surgery.

 

[Beach77]

When I had my surgery, I went to a local hospital in San Diego. All the bills came separately, so maybe the CC hospital's part is what they will accept but the doctors & tests will be bill separately. My total charge-before insurance was over your $275k. I was really happy with my doctor and hospital!

 

[KarenK]

dick0236 The CC actually stated, "it would be illegal" to have a document of the agreement in writing. Unbelievable.

No local surgeons for me. My sister had SAVR locally and went from the hospital into a rehab facility and died a short time later.
Arkansas is rate 49 out of the 50 states in medical care.

 

[slipkid]

Terrible....gotta love the state of healthcare in this country (not!). Don't get me started. Sorry for your hassles. I've been through similar things on a much smaller scale though.

 

[carolinemc]

My ins. denied coverage. CC did an urgent peer-to-peer appeal. CC called when the urgent appeal was to be completed, said it was denied and ins. co. won’t respond again until 11/2, surgery is 10/24. So we’re in the 2nd level of appeals. CC said my case was submitted to the powers that be and they would go ahead and do surgery and deal with the ins. on the backend. CC also said that they were going to except what the ins. pays and I only need to pay $275 and I wouldn’t be liable for anything else. Said they were a non-profit and this is what we do to assist when needed.

It didn’t seem right, I was very doubtful. I talked to the drs. office the next day about the surgery being off. The assistant had the managing NP call stating the same thing about the limited charges to me.

So thing are moving along and I start to hear little tidbits of info. from various people that conflict with what I’ve been told regarding coverage and that the urgent appeal was never filed.

I’m supposed to fly to CC this Sat. Yesterday I received 14 requests for info for pre-op tests and these requests include payments I’m to make before testing. There’s also a doc. to sign that says I will be 100% liable if ins. denies coverage or any and all amounts that ins. doesn’t pay. This was not what I was told.

I just received a partial estimate for surgery, $278,840, that doesn’t include the anesthesiologist, any other drs. or personal involved.

I asked for additional estimates. I received a partial again of $21,000 for some of the pre-op. On the hospital stay I was told, “we don’t do estimates on that because we don’t know what the charges will be”. Huh, CC doesn’t know how much they charge for rooms in their own hospitals? I did see on their site that ICU and cardiac rooms are $6,200 a day. 5 days would be another $32,000 plus I would assume much greater charges for all that goes along with that.

Today 2 different people read to me the original agreement that I mentioned at the start. When I asked for a copy, one kept saying no, and the other said it was illegal! When did it become illegal to document the terms of an agreement between parties?!

Known charges are $330,000, my guesstimate is charges may be $450,000. (10 yrs ago I had a craniotomy at the Mayo Clinic for a leaking brain aneurysm that was $100,000. That’s a 35% increase every year to get to $450,000.)

Kinda feels like bait and switch. So, at this late date I now have no protection if the ins. continues to deny coverage. The CC could decide not to proceed with challenging some or all of the denials. Then it all falls on me.

The CC didn’t follow through on the ins. appeal in the past… they may not in the future when they have another funding source…me. Lost my trust in the CC, I’m going to cancel my surgery.

I feel for you, for the initial surgery is cheaper than the hospital stay, surgery room, the heart and lung machine used, the surgical staff, and medications used during surgery and during the hospital stay, ICU for recovery. It is mind blowing how it is so much more than it needs to be. And this is with insurance.
When I had my second bypass with Aortic replacement, they tried to get me to pay all of the cost of the heart and lung machine, that I should have been awake to tell the surgical team to call the insurance to make sure the heart and lung machine was covered. I fought with them for 8 months till someone had some brains and realized I had no responsibility over the heart and lung machine, and they dropped the billing from me and decided who was. Crazy. For you need the surgery. Do not delay, go to another route, for you cannot be denied due to not having medical insurance. Good luck and fight, for life is worth fighting for.

 

[carolinemc]

Terrible....gotta love the state of healthcare in this country (not!). Don't get me started. Sorry for your hassles. I've been through similar things on a much smaller scale though.

I even got billed for heart and lung machine, they expected me to be awake during surgery to find out if the heart and lung was okay by the insurance company. Took 8 months, the case person worked hard with the idiots till they finally dropped it and decided I was not the person to fight. That was stressful. But this girl was tough then as she is now.

 

[carolinemc]

dick0236 The CC actually stated, "it would be illegal" to have a document of the agreement in writing. Unbelievable.

No local surgeons for me. My sister had SAVR locally and went from the hospital into a rehab facility and died a short time later.
Arkansas is rate 49 out of the 50 states in medical care.

So sorry for your loss. Not all are like that. But that is everywhere, not just in Arkansas and not in all local hospitals. I am lucky in my chosen hospital. They have changed a lot, a teaching hospital, in their patient care. Not all teaching hospitals are good. But the one I go to, makes sure to do what testing is necessary for I am not just Heart bypass survivor, I am also a type 2 diabetic and neuropathy in both feet, the left foot was officially diagnosed, I will get the other foot checked next year. Am on insulin and Trulicity for my A1C, which is good now. So, I feel lucky, but this place I am at now, was not always a great place. it is hard to get good medical care in the USA. Many specialists are in it for the money. I had one cardio that took my BP and said only this, "it is over 500."??? I was shocked and speechless. Never took the blood pressure med he prescribed. Got with me PC at the time and she had me come to her office three times and said I was fine. I do take them now, but for different reasons. So sad at the state of Medical Care here in the USA.

 

[carolinemc]

When I had my surgery, I went to a local hospital in San Diego. All the bills came separately, so maybe the CC hospital's part is what they will accept but the doctors & tests will be bill separately. My total charge-before insurance was over your $275k. I was really happy with my doctor and hospital!

All hospitals in America have gazillion bills for millions of things done. I was lucky with my bypass; the bills were covered. And the only problem I had was for the heart and lung machine, which the people over that tried to collect till I kept fighting back and had a good company worker on the case. Not held responsible for it, for I could not wake in the middle of surgery and say, "do you call the insurance company to see if the heart and lung machine is covered for bypass surgery?" It was a crazy time, happened 6 months after surgery. Was glad when it was over, took 8 months for them to stop the harassing bills.

 

[ashadds]

Can you travel for surgery ? perhaps to india

 

[Gail in Ca]

India??
If I’m going to travel I’ll go to Stanford!
Or here at Cedars!

 

[Unicusp]

I've been to the CC twice. They are the best for your required procedure. They are also significantly less expensive overall as compared to any other large facility (in NA) in my experience. They provide one comprehensive bill. You will not receive separate bills for services. All service providers are employees of the CC, not independent contractors.
Your fight is with the insurance company, not CC. As this is required surgery, I say go forward with the CC and deal with insurance separately.

 

[Gail in Ca]

My daughter had a test with contrast. When we got there at 6:45am the reception said the insurance hadn’t responded yet about approval. My daughter is sick and we were there, so she had the test. The insurance did end up covering it but sent a less than positive letter stating this was a one time thing and in the future they won’t pay if the approval hasn’t come through.
It’s a big insurance company and I’ve had issues with them and prior auths.

 

[MIB]

My ins. denied coverage. CC did an urgent peer-to-peer appeal. CC called when the urgent appeal was to be completed, said it was denied and ins. co. won’t respond again until 11/2, surgery is 10/24. So we’re in the 2nd level of appeals. CC said my case was submitted to the powers that be and they would go ahead and do surgery and deal with the ins. on the backend. CC also said that they were going to except what the ins. pays and I only need to pay $275 and I wouldn’t be liable for anything else. Said they were a non-profit and this is what we do to assist when needed.

It didn’t seem right, I was very doubtful. I talked to the drs. office the next day about the surgery being off. The assistant had the managing NP call stating the same thing about the limited charges to me.

So thing are moving along and I start to hear little tidbits of info. from various people that conflict with what I’ve been told regarding coverage and that the urgent appeal was never filed.

I’m supposed to fly to CC this Sat. Yesterday I received 14 requests for info for pre-op tests and these requests include payments I’m to make before testing. There’s also a doc. to sign that says I will be 100% liable if ins. denies coverage or any and all amounts that ins. doesn’t pay. This was not what I was told.

I just received a partial estimate for surgery, $278,840, that doesn’t include the anesthesiologist, any other drs. or personal involved.

I asked for additional estimates. I received a partial again of $21,000 for some of the pre-op. On the hospital stay I was told, “we don’t do estimates on that because we don’t know what the charges will be”. Huh, CC doesn’t know how much they charge for rooms in their own hospitals? I did see on their site that ICU and cardiac rooms are $6,200 a day. 5 days would be another $32,000 plus I would assume much greater charges for all that goes along with that.

Today 2 different people read to me the original agreement that I mentioned at the start. When I asked for a copy, one kept saying no, and the other said it was illegal! When did it become illegal to document the terms of an agreement between parties?!

Known charges are $330,000, my guesstimate is charges may be $450,000. (10 yrs ago I had a craniotomy at the Mayo Clinic for a leaking brain aneurysm that was $100,000. That’s a 35% increase every year to get to $450,000.)

Kinda feels like bait and switch. So, at this late date I now have no protection if the ins. continues to deny coverage. The CC could decide not to proceed with challenging some or all of the denials. Then it all falls on me.

The CC didn’t follow through on the ins. appeal in the past… they may not in the future when they have another funding source…me. Lost my trust in the CC, I’m going to cancel my surgery.

That's scary. You didn't say what insurance you have. I'm guessing you don't want to name them for fear of retribution. I'd appreciate who and what type of insurance. If you send me a message that's fine and I won't say anything.
My company is trying to force us on their preferred plan. It's either that or no medical. I'm seriously concerned that exactly what you're dealing with will occur.
Good luck and TIA.

 

[AZ Don]

I know nothing of CC other than their reputation as the best cardiac hospital in the world, but when anyone is making verbal promises that they won't back up in writing, that is a red flag. Perhaps if you cancel/postpone the surgery they will have more incentive to sort this out with your insurance before hand. IDK what the issue is with your insurance and whether you will have the same problem with another hospital. I would not go to just any hospital for heart surgery, but a top regional hospital should be sufficient. There are some top heart hospitals in Texas (Houston and Dallas) and a Mayo Clinic in Florida. US News ranks hospitals by specialty and can search w/i up to 500 miles of a given location.

 

[Croooser]

I had an excellent experience with CC, including all financial aspects.

Understand not willing to go forward without assurances of what your responsibility is.

What is the reason for denial from the insurance company? Seems like this is the real issue?

 

[MdaPA]

As Croooser mentioned, do you know why your insurance originally denied it? e.g. maybe they required a test or form that was not submitted or was missing info?

Have you spoken to a supervisor or an advocate at your insurance company so they understand they need to make a decision sooner then they told you (as your surgery is before their review date)? Sometimes things get lost in the shuffle and a brain needs to step and get things moving the right way.

Have you reached out to your state's insurance ombudsman? I attached the link below to file a complaint but I would first call them to get them involved as you don't have much time.

I provided their link below:

Arkansas Insurance Department

Sorry you have to have this grief a week out from your scheduled surgery.

 

[slipkid]

India??
If I’m going to travel I’ll go to Stanford!
Or here at Cedars!

I was hoping it was a typo meant to read as Indiana (rather than India!).

 

[ashadds]

Oh I was talking about OP , who couldnt afford surgery. Its common to travel to other countries for surgery if you cant afford it

 

[carolinemc]

Oh I was talking about OP , who couldnt afford surgery. Its common to travel to other countries for surgery if you cant afford it

If you could not afford the surgery, the trip and stay would be expensive also. No money. And not common for poor people to travel with no money to get surgery with no money.