Insurance-Out of Network Approvals

[JoeG]

Hi everyone

I'm meeting with Dr.Louis Lanza this morning I hear he is highly qualified however, he is not (in-network) with my insurance. Does anyone have any information on having your insurance approve an out of network surgeon? I called my insurance and they said they will pay out of network "reasonable and customary fees" so then I called the Mayo Clinic where Dr. Lanza performs his surgery's and they advised they are on the "high end" as far as fees. Am I going to have to come out of pocket for any extra fees or is there a way to offset these additional fees or have my insurance approve them?

 

[john79t]

In a former life I sold insurance to include health. The insurance company will pay their UCC part and you will pay your deduct. What Mayo is telling you is that they will not accept the UCC as full payment and you will personally be responsible for the difference. Example you have a $10000 bill. Your insurance might say the UCC is $6000. They pay 80% of the 6K or $4800 and you pay the 20% $1200 plus the $4000 that is not covered.

If you have time you may want to shop around for a good hospital and surgeon that will accept the UCC as full payment or a least work out a lessor amount with you or the insurance.

Hope that helps shed some light.

 

[john79t]

Joe my daughter went to Mayo in Mn. She had her back evaluated and the one day was over $1500 to her part.

That being said I would shop around but if there is a choice between a great surgeon and saving money I would go for the surgeon.

 

[Mary]

To get out of network approval, I think you have to show that there is a medical reason why you are seeking care outside your own insurance providers.
Back when I was looking at replacement, I could have gone out of network for the Ross procedure since no one in network performed it.

 

[john79t]

Mary
That is true but unless the insurance company or you get the dr and the hospital to agree to accept the UCC as ful payment you can still owe a bundle. However, if that is what it takes to get good care I would worry about the bill later.

 

[ALCapshaw2]

Joe,

There are different levels and areas of "Highly Qualified".

A "highly qualified" ByPass Surgeon may have next to ZERO experience repairing / replacing an Aorta that is compromised because of a Connective Tissue Disorder.

You need to have your Aorta assessed by someone who knows how to do that. Then, IF you have a connective tissue disorder, you need to find a Surgeon who has experience repairing / replacing defective Aorta's.

Be sure to ask every Surgeon you interview about their experience with BAV and Connective Tissue Disorder, how they would assess such conditions, and how much experience they have repairing / replacing parts of the Aorta, including the especially complex Aortic Arch.

Did you see the recent replies to you other thread,
especially the one from the lady who needed her Aorta repaired because of "thin tissue". You need a Doc who can find and diagnose such 'thin tissue'.

I'm assuming you would prefer to get 'everything' fixed the First Time as opposed to discovering that you have an Aortic Aneurism on the verge of rupture 5 years down the road.

'AL Capshaw'

 

[Mary]

Mary
That is true but unless the insurance company or you get the dr and the hospital to agree to accept the UCC as ful payment you can still owe a bundle. However, if that is what it takes to get good care I would worry about the bill later.

You would know beforehand how much they will pay. It has to be preapproved if it's out of network, and usually in network, or else insurance will pay ziltch.
I realize it can be a bundle of money. Have you considered looking at the list of doctors who are in network with UCC, and then checking their qualifications?
And you can still see the surgeon from Mayo, get his opinion, and then switch surgeons if you need to.

 

[kfay]

I can tell you about my experience with the Mayo clinic. My bill, when all was said and done, was around $120,000. Luckily for me, BCBS of North Carolina considers them in network for me. However, when the bills started coming in, BCBSNC had originally denied a bill for around $37000.00 When I called the Mayo clinic, they told me that I was responsible for any and everything my insurance didn't pay and that they didn't discount for "usual and customary" charges (in other words, if the insurance said "x" procedure was only worth $1000, and they charged $2000, I was responsible for the difference).


My billing issues got sorted and I had to pay a grand total of $60.00 out of pocket. I think that you can call them and they will give you an estimate of what you would have to pay out of pocket. I would definitely do this in advance so that you know what you are looking at.

Also, just FYI, my bill for two days of testing and meeting the surgeon and cardio before I went there for my surgery ran close to $8000 if I recall correctly.

Hope this helps. I had a great experience there and would recommend it if you can work it out.

Kim

 

[john79t]

Al had good advice.
Do your home work and get the cost as good as you can. However, the extra cost is a lot easier for you to pay when you are healthy than your family if you are gone. If the surgeon has not done a couple of humdred aorta repairs with good results don'tuse him even if he accept your insurance for 100% pay.

 

[Lisa in Katy]

You would know beforehand how much they will pay. It has to be preapproved if it's out of network, and usually in network, or else insurance will pay ziltch.
I realize it can be a bundle of money. Have you considered looking at the list of doctors who are in network with UCC, and then checking their qualifications?
And you can still see the surgeon from Mayo, get his opinion, and then switch surgeons if you need to.

That's not true for all insurance companies. I can go out of network any time I want. My insurance doesn't require pre-authorizations, just notification after admission. However, like John said, if there is a difference between what they bill and what is allowed, I am responsible. I do have a maximum out of pocket for out of network services, but the difference between allowed and billed doesn't go toward that max - just the difference in the patient portion designated by the plan.

Luckily, there is only one hospital and a handful of physicians in the Houston area that aren't in my network.

 

[Mary]

That's not true for all insurance companies. I can go out of network any time I want. My insurance doesn't require pre-authorizations, just notification after admission. However, like John said, if there is a difference between what they bill and what is allowed, I am responsible. I do have a maximum out of pocket for out of network services, but the difference between allowed and billed doesn't go toward that max - just the difference in the patient portion designated by the plan.

I had to have authorization for valve replacement both in network and out, but as you say, insurance companies differ. I would want to have written certification before I undertook anything like OHS.

 

[kschul]

I just went through this exact thing and was able to get pre approved as being covered in-network because the surgeons in-network for me were not doing my procedure very often. They then told me about the usual and customary charges I would be responsible for because they did not have a contract with the hospital that I chose. I called the hospital and found out that they are under contract with my insurance just under a different PPO so I will be covered. Check to make sure even though your exact PPO (if that is what you have) is not covered they may still have a contract with your insurance company. I hope that this makes sense.

kris

 

[Lisa in Katy]

Actually Joe, Kris makes a good point. Look at your card and see if there is another logo. For instance, on the back of my card toward the bottom, there are two words "shared savings" and underneath is a logo that says MultiPlan. What that means for me is that if I go out of network, but the provider has a contract with MultiPlan, I will still have to pay my out of network deductible, but I will not be responsible for the contractual write off.

My husband's card, on the other hand, specifically says that there is no out of network benefit except in the case of an emergency.