Insurance Issues- RRRRRRR

[BarbJean]

Not sure if this is where I should post this question. I am sure most of you are better at navigating insurance issues than most people based on your experience. My son, Colin, will be needing surgery soon on his aortic root due to Marfan Syndrome. I called Empire to see how many opinions we were able to get. I planned on talking to four surgeons for consults. The insurance rep told me we can get an unlimited number of second opinions, but that the first surgeon that recommends the surgery is the one that has to do it. Colin will be having an MRA done in Philly where we see Dr. Reed Pyeritz, a medical geneticist. So-the question. Do I make sure I know which of the four I want to use before even seeing one of them about the surgery, since the first one we see will be the one that has to do it in order to be covered? I am so confused!!! I will be away from my computer most of the day, but will check in later to see if any of you have the magic words to explain this to me. As though surgery isn't stressful enough. Thanks all, Barb

 

[AgilityDog]

I don't know who your insurer is, but that makes no sense whatsoever. What if the first surgeon you interview says the surgery needs done but it's not in his skill set? I've never heard of a rule like that.

 

[BarbJean]

Laurie, Great question!!! I am going to ask them that. I figured we are safe seeing our geneticist first since he can't do the surgery. Our insurance is Empire Blue Cross which I just figured would cover anything.

 

[Jkm7]

That's crazy. Half of the point of getting other opinions is not only to determine if surgery really is necessary but to find the surgeon most in your comfort zone.
Ask to speak with another rep at Empire.

Put it right to them...... What if there is no 'chemistry' with the first surgeon and my son is terrified of him operating?
What if I don't feel comfortable with the answers he provided for my questions?
Create a list of scenarios that maybe will help them see your point.

Good luck and please let us know what happens.

 

[kfay]

I, too, have never heard of such a crazy rule! I have Blue Cross as well (different state) and don't have anything like that in my policy. I have heard of insurance companies limiting the number of opinions they will pay for, but never saying you have to go with the first surgeon. I'd ask for a copy of the policy where this is stated to be highlighted and sent to you. Then I would appeal it! Good luck.


Kim

 

[nngbwh]

I agree with the others. Make sure you have a notepad and pen handy so you can jolt all the information.

 

[BarbJean]

Thanks all! I spoke to another rep who said she was going to research it and get back to me. Surprise! She did not call me back. I will call them again tomorrow morning and let you know what they say. I am getting my pad, pen and stories ready. All I can say is ------ Thank God I found this message board!!

 

[Jkm7]

The issue you might have is your son is 24 years old. Without prying into private information, unless he is not emancipated for whatever reason, he is an adult and you might encounter conversation about him making these decisions etc

Not to give you anything else to stress about. I truly am sorry you need to deal with any of this. It's lousy but it is the hand we all got dealt.

 

[Ross]

You can borrow my .357 Mag and go have a persuasive talk with them.

If that doesn't work, I got a line on a nice used Howitzer.

 

[Bill B]

I agree that is about the stupidist thing I've ever heard. Unlimited opinions but only the first one matters. Wow!

This is consistent with my experience with insurance company customer service - you are likely to get a different answer each time you call.

 

[BarbJean]

Ross, believe me, I have considered that. A customer service rep for an insurance company takes their life in their hands.
JKM, I have always had my son sign the Hippa agreements so the docs, etc, would discuss things with me. I know the time will come when he will be the one to answer to these questions. Right now, I think he is perfectly willing for me to handle it all. Can you tell I am a control freak?

 

[Star54]

That is totally stupid. Ask for a copy of the clause in the policy that states that rule. I hope you are getting the names of the representatives you are speaking to. If they do not call you back, call them. This time if you hear the recording as you wait for a rep saying "this conversation may be recorded for quality" tell them you are recording it as well. I would also find out an administrator's name and e-mail them of your concerns. It is better in writing as they cannot deny what they tell you.

Lot's of luck and keep us posted on your success...

 

[Luana]

You're not a control freak; you're a mom!

What the ins co is telling you sounds like nonsense to me and I am a licensed ins agent. Is it an HMO or PPO plan? I'm guessing it's PPO, and I don't think you should have a problem selecting a surgeon. Hate to say it, but the customer service people are very low on the totem pole and when I was working never called them; they're one of the least reliable sources.

While I did have the surgeon my cardiologist referred me to do my AVR, had he not referred me to him, I would have asked for him. You usually have that freedom even with an HMO, as long as they're in the network, and surgeons usually participate in as many plans as they can, for more referrals. Years ago when I had back surgery, I did see several surgeons. I picked the guy who had teddy bears in the exam room.
Luana

 

[buncle]

I have BCBS in texas.I wouldnt go with what someone told me on the phone.I would read my policy.What is in writing is what your covered for.
I am not sure about yours but, mine is easy to read and understand.If yours seems complicated ask a friend to read it with you and maybe you can
get the answers you need. Best of luck!

 

[BarbJean]

Thanks, all. Plan on calling them again first thing in the morning and telling them I want to speak to a higher up on the totem pole. I will ask them to send me the part of my plan description that shows me the ridiculous info they are handing me. You have all convinced me. I will be tough! I am woman, hear me roar.

 

[Luana]

Barb,
You should be able to get all the details of the plan online. What you want to read is the EOC, evidence of coverage, which is usually about 90 pages, compared to the SOB, summary of benefits, which is maybe only 3 or 4 pages.

 

[Ross]

Barb,
compared to the SOB, summary of benefits, which is maybe only 3 or 4 pages.

Umm, I think you were right the first time. So SOB is Summary of Benefits. I've been wrong all this time.

 

[BarbJean]

Just spoke with the insurance company and they are still investigating the issue. Then, I called the woman who takes care of our group benefits in the school district I retired from. She said it actually works that way- the second and third opinions are just to confirm whether surgery needs to be done, but the surgery needs to be done by the first doc recommending it. I looked in my coverage booklet and this is how it reads: "We will pay for a second opinion with respect to proposed surgery upon the following conditions:The specialist who renders the second surgical opinion does not also perform the surgery for which the second surgical opinion was obtained. " So, I was told that I would be better off to pay for the consults out of pocket and not have claims submitted. Then, after choosing who we will use, have that doc submit the claim as the surgeon recommending surgery. Talk about crazy, but if that is how we need to do it to go with who we want, I guess we will have to. I think we are narrowing it down to two surgeons at this point, so it would mean paying for one consult which is not too bad. I did try to look up the EOC online but all it has is the SOB. I feel for those of you who were ones needing surgery and also having to deal with the business end of the whole issue. At least Colin does not have to worry his pretty little head about this stuff-I worry my not so pretty little head.

 

[Lynlw]

We have NJ BCBS (horizon) it is a PPO if that matters and IF e had that rule, I never heard of it (actually I don't recall every asking them about 2nd opinions I just went and got them) but I do know for a fact. That for Justin's 4th surgery surgery went went with a different surgeon/center than was the 1st one we talked to after the cath and everything was paid for. As a matter of fact we even had surgery schedualled (a couple times) at 1 center that was postponed and we decided to go elsewhere for the surgery with no insurance problems
Beside asking the insurace company I would alos call the different doctors/center you want the opinions on and ask how they handle things like this, since I am sure IF your company has this rule other do and they know how to handle everything. Especially the major centers., since you know many people who end up having surgery at the major centers and traveling were first told by local doctors they needed surgery and the larger center would be the 2nd opinion and gets paid for their surgeries.

My other thought is I wonder if it wold matter what kind of 2nd opinion or even 1st opinion it is. meaning is it an inperson visit or by the records. I know for Justin alot of his opinions are from records/cds and many of the leading CHD center will do them for free as a courtousy, maybe if the opeinons are by record and as a courtousy that gets around the stupid rule. IF this was how most worked noone would probably be going to larger centers since they would have to pay for the surgery.

So I would call both the insurance company and call the doctors you have the appointments with and ask them what to do

 

[Luana]

It's good that you have a benefits administrator to refer to but the rule still sounds pretty odd.

So, let's hypothesize that the second or third consult could do a less-invasive or a more advanced and/or safer procedure, and perhaps might even charge a lower fee, the ins only goes with the first one?

I would bet you almost anything the EOC is online. If you call them and ask them to mail you one they'll give you a speech about how "everbody's going green now and we don't mail these out anymore, but it's on the Web site." Bingo! And your response would be, "Will you email me the link to it, or an attached PDF?"