Insurance

[Christian]

My wife's being seen at the Cleveland Clinic. We have insurance through Aetna U.S. Healthcare (HMO), and the Cleveland Clinic is "in network."

We considering switching insurers, but I don't know of any company aside from Aetna that will cover (even partially) surgeries performed outside of the local region.

I'm sure there has to be some. I'm just ignorant when it comes to health insurance.

If any of you have had surgery far from home, did your insurers cover it? If so, which companies insure you? I'm especially interested in hearing what the Cleveland Clinic veterans experienced.

 

[Dave M]

Christian,

Our insurance is Arkansas Blue Cross/Blue Shield. I did not have my surgery at Cleveland Clinic, but I had a full evaluation performed by one of their cardiologists before my surgery in Little Rock.

I did not know it at the time, but our particular plan is linked up to Blue Cross/Blue Shield plans nationwide. As long as the provider is in the Blue Cross plan for that region, we are covered. Cleveland Clinic is in the network for Anthem Blue Cross/Blue Shield of Ohio, so all my expenses there were covered.

To sum it up, there are some options out there.

Dave M

 

[Christian]

Thanks for the quick response!

That's exactly the answer I was looking for, down to the particular provider. I have access to Highmark Blue Cross/Blue Shield in PA. I'd be thrilled if the CCF was "in network" -- even if I had to pay 30%.

Has anyone else had a similar experience?

 

[Mara]

Wait Christian,
Don't do anything rash. I had the same Aetna you have and they paid all of my Ross Procedure except for $250! that's pretty darn good for a $45,000 surgery!!!!
I wish I still had Aetna, but my employer switched to United Healthcare and NO ONE takes it. My cardio nor my surgeon, so my check ups are not covered!!!! Arghhhh!
-Mara

 

[ALCapshaw]

WHOA ! Before changing horses in mid stream, BE SURE that pre-existing conditions are covered. You definitely DON'T want to cancel an insurance policy before you are guaranteed coverage by another.

'AL'

 

[hensylee]

Be careful of changing - this definitely is pre-existing and usually you must have a pre-existing illness at least 2 yrs before coverage for it. Also if you decide to change after surgery there is always the danger of being turned down so cover all the bases before you decide. Then get it in writing - and signed. God bless

 

[Gail in Ca]

Believe me, you don't want to pay 30%!!
I chose a non contracting surgeon the 1st time around and ended up owing lots of bucks out of pocket. And that was just the surgeon.
And it was covered at 80% of reasonable and cust but of course what is charged is always above the r and c and you must pay any over.
I had bl cross last go round and my total surgery cost me $0. All contracting drs and hospital.
Gail

 

[Freddie24]

Hi Christian,

I also have Aetna. I had my surgery at Toronto General Hospital in Canada. I live in California and they still covered me 100%. They initially tried to decline coverage b/c it was out of the country but I appealed it and they granted full coverage. I was quite impressed actually since I didn't have a pay a single cent for my OH surgery. If I were you, I would stick w/ Aetna. Good luck and let us know what you decide.

-Freddie24

 

[JenniferO]

I have United Healthcare of Utah as my primary insurer. I was not given very good odds of repair of my mitral valve by local surgeons so sent my diagnostic films to Dr. Cosgrove at Cleveland Clinic. Because Dr. Cosgrove was able to give me such a high percentage of repair (95%), I appealed to my insurance company to let me go out of network to Cleveland Clinic. They did grant my appeal and so they are paying the "allowed charges" (their judgment) at 90%. The problem comes with the disallowed charges which I still owe. For instance, the hospitalization bill was over $44,000. United chose to pay only $37,000. I'm still holding the bag for the rest, since Cleveland Clinic does not have any contractual agreements with United Healthcare of Utah. [They do contract with United Healthcare of Ohio, but that is not the same thing. United does not have the reciprocal agreements between its state organizations like Blue Cross/Blue Shield does].

In October, during the "open" period in my husband's employment, I did sign up for Blue Cross/Blue Shield as a secondary carrier. This is BCBS of West Virginia. Cleveland Clinic is considered "in network" by Blue Cross and because of the reciprocal agreements between the various state units of BCBS, I hope that eventually whatever United didn't cover will be taken care of by BCBS and any disallowed charges eventually written off since Cleveland Clinic does have a contract with Anthem BCBS. This is the way it was explained to me by BCBS Customer Service.

All this being said, those Cleveland Clinic bills that I'm currently receiving are enough to put you back in the hospital with a cardiac arrest.

As for the fear about a pre-existing clause, as long as you have been continuously insured at the time you apply for the new insurance and have had no lapse in coverage, they cannot apply a pre-existing clause. I told BCBS I had been advised to have mitral valve surgery. You can tell them you need a head transplant and they cannot deny coverage as long as you haVe been continuously insured. If you have not been continuously insured, I believe the law is that they can impose up to a six month waiting period, but that has to be decreased by the number of months you were insured in the previous six months before your application. Something like that. There is a whole website that explains the law on this subject. My notes are at my office. If I can find it, I'll post the URL.


What's worrying me also is what is going to happen to my health insurance premium with United during my employer's open/renewal period in August. In the meantime, my husband's job is changing so we will not have the back-up coverage with Blue Cross/Blue Shield.

 

[JenniferO]

Here is that URL on your rights under the Health Insurance Portability and Accountability Act:

http://www.hcfa.gov/medicaid//hipaa/online/010240.asp

 

[Christian]

Actually, the pre-existing question isn't an issue. As you noted, we're protected under HIPAA.

That said, it was still nice to hear that I'd get at least partial coverage elsewhere. I have no problem paying $$ to get the physicians we want -- I've set aside 20% of the expected total fee already (since we've known about this for so long, we've had time to prepare).

Jennifer, I was interested in your 95% quote from Cosgrove. I read elsewhere that you were getting 50-75% from other doctors.

Jill was told by Dr. William Stewart at CCF (a valve & echo specialist, not a surgeon) that her odds of repair are 70-80% (I consider that a 75%). Her echo results were also sent to Dr. Stephen Bolling at UMich. in 2000 (a well-known valve surgeon) -- he gave her a 99% chance of repair.

I'm not sure who to trust, because I have no idea how these odds are derived. Dr. Bolling saw nothing but regular echo tapes, and anterior repairs (Jill's regurgitation is mostly caused by a bad anterior leaflet) are supposed to be more tricky. So I'm a little skeptical about his optimism.

But Dr. Stewart has nothing more than stress-echo results to go on -- I'm not sure whether that's materially different.

I think maybe we should go talk to Dr. Cosgrove and see what he thinks. If we had a 95% chance of repair, we'd probably just elect to get the darn thing over with.

 

[JenniferO]

I think it's the surgeon's opinion that you need. Dr. Cosgrove had a regular echo and a TEE film to look at when he gave me my 95% odds. The TEE film was the important one in that it gives a much closer and better look at the valve. In fact, until the home surgeons saw the TEE, they were giving me more like 80% odds. The odds went sharply down when they observed the TEE. The home surgeons were less confident about the possibility of having to do an anterior leaflet repair. Dr. Cosgrove does them all the time. As it all turned out in my case, Dr. Cosgrove repaired the posterior leaflet, put on a Cosgrove ring and didn't have to do anything to the anterior leaflet.

I have heard of Steve Bolling at U of Michigan. There was a very good program on Discovery Health channel on cable TV last November or so which profiled a patient with mitral valve regurgitation and Dr. Bolling was the surgeon. He certainly seemed an excellent surgeon. He did however use the full sternotomy approach to do the job. Dr. Cosgrove can probably do your wife's surgery with a mini-sternotomy. My incision is only 2 5/8" long. I'm really glad I didn't have to go the full sternotomy route.

 

[Christian]

I'm not sure exactly what a TEE is. If it's the "down the throat" test, Jill's never had one. It's pretty invasive, isn't it?

 

[JenniferO]

Yes, it's the "down the throat" one and as Ross Y. recently posted, some have a difficult time with it but having done 4 of them since October (one was during my surgery and 3 were conscious), I now consider myself very experienced with this procedure. In my opinion, it sounds worse than it is. If they spray your throat thoroughly enough to be sure it's numb and give you enough sedative, there's really not much to it. For me, the worst was the sort of burning/choking sensation you get momentarily when you have to swallow the stuff sprayed on the throat. For me, the scope went down easy, no problem. They gave me a good dose of Versed and a little morphine and I was completely relaxed. It takes no more than 15-30 minutes and since you're on the drugs and a little out of it, it feels more like 5-10. I did have a sore throat after the first one and none or only slight after the others. I think it's well worth it for the better information it gives.