View Full Version : Insurance
01-06-2010, 11:34 PM
Is anyone seeing a NS or PS that is non-participating with your insurance? Do insurance companies ever approve out of network doctors for this surgery? I am just not sure if there are any doctors in my area with enough expertise in this. I have found a couple of doctors that I would like to travel to interview and possibly have do the surgery but I don't think my insurance with cover it.
01-06-2010, 11:44 PM
i am wondering the same thing, what i did was call the insurance company and asked for authorization but they told me i needed my dr to do all that (not sure if thats how it will work for you) but i would start by calling the insurance. but the ladt told me that i might get denied if there were doctors in the network that can do the same thing. but i plan on fighting it since ive been waiting almost 3 months to see a dr since her scan. best of luck and let me know how it works out for you
01-07-2010, 06:27 AM
Some of us have had luck going out-of-network, but your best bet is to get it approved up-front. In our case, we had already had bad experiences with the only in-network surgeon. It is a lot of work, but well-worth it if you have good reason for not wanting to use your in-network docs.
01-07-2010, 07:26 AM
GET IT APPROVED UP FRONT........but it can be done. Several on here have been successful. Also in the Resource section I believe there is a link to The Insurance Warrior and she has some very good advice on how to go about it.
01-07-2010, 08:08 AM
I agree....Get approval (in writing) before surgery if at all possible. Many of us who went out of network were told by our ins that NOTHING could be done to "appeal" our case and/or get approval until AFTER surgery, only to learn that all ins companies have policies in place for such situations.
I also agree about contacting "The Insurance Warrior" Laurie Todd. She has some great tips to get your ins to pay up and I know she has help a few of the ladies here get their kiddos surgeries approved. A couple members I can think of right now are Heather (user name Nezzy) and Kristin (evergreen mom). Heather's surgery was approved (with Lauries' help) before her sons surgery, but Kristin had to fight hard to win her appeal after her sons surgery. I think they both could give you a lot of insight and advice on how to proceed. Don't rely solely on your doctors or surgeons office to get surgery approved....this is your fight and the ins knows it.
Best of luck and keep us posted. Hugs.
01-07-2010, 11:11 AM
We used an OON group. It took a lot of arguing with the insurance co. but I got the approval. The bad thing is for any and every follow up or anytime I feel I need to see the docs I have to ask permission. For us they only approve one visit at a time. Then they approved surgery and one post op visit. Then I had to call and tell them when the next post op would be and the docs had to send in paperwork explaining why we need the appointment and every subsequent appointment. It is a pain, but well worth it to go to the docs of my choice.
01-07-2010, 12:24 PM
It is hard work, but you can get it approved with an appropriate insurance appeal. I did it with the help of Laurie Todd, The Insurance Warrior. Please PM me if you need additional help or info on Laurie. Find the docs you want and then push to get them covered. I do not recommend choosing a doc based solely on insurance.
01-07-2010, 03:42 PM
Welcome to ck...sorry you had to find us, but I hope we can help. What kind of Cranio does your child have? Who diagnosed her? Where do you guys live? This is a very serious surgery and you must find a doctor that you trust. We can help.
I had to fight long and hard and had a really horrible year dealing with our insurer after the fact but we went ahead with surgery with Dr Fearon without pre-authorization because our in network docs could not show us good clinical outcomes with our sons type of cranio (lambdoid- very rare), and because they failed to diagnose his Chiari malformation (a related condition) which Dr Fearon's team found and treated during Xander's CVR. My insurer finally agreed to pay in full for Xander's surgery but I so wish I had known to fight up front when time and Xander's health were imperative and when I had the leverage necessary to make my insurer pay asap! It would have been quicker and easier and I wouldn't have had so much stress for a whole year over this $@#&!!
My insurer lied to me repeatedly over the phone saying there was no pre-approval process for out of network care. While doing my appeal with the help of Laurie Todd and her great book "How to fight your insurer and win" I found there was a whole process in place for getting out of network care covered as though in network. They had a grievance process and an expedited external review that we could have done (had we known to) which I am sure would have resulted in our insurer agreeing to pay up front for our son's surgery.
Insurers lie and play games and do whatever they can think of doing to get away with not paying. They are not your friend!! Do not believe them!! It is your job not the doctors to get your insurer to pay. It is hard, but not impossible!! Don't trust what they say on the phone...read the entire website for clues about making your case and do your correspondences in writing!
My advice is to quickly line up consults with several docs who you have reason to believe are good- I believe there are many good network docs out there. Tell us where you live and folks on here can advise. If you have heard good things from others on here and you have a good impression of them and feel like you will be comfortable using them - Great! Use an in network doc. But if you do not have that feeling of confidence and comfort and you are only able to find that with someone out of network then go with your instincts and prepare to fight!
You can hire Laurie Todd- she is great at pushing these cases through the red tape. You can also ask us questions about how to fight your insurer. Too many of us have experience fighting, only some of us have won but since we learned about the insurance warrior and her techniques I think it will be easier from now on! Good Luck and keep us posted!
01-07-2010, 04:22 PM
I second much of what Kristin said. No matter how "nice" the person sounds on the phone, remember, they are NOT on your side. They are not health care professionals. They do not care about your health, only their profits. They make their money by denying your care. Get everything in writing. Take names of people on the phone and dates and times you call, but ultimately, get things in writing.
And while you are at it, call your senator and representative and tell them not to support this health care DEform bill in Congress that will REQUIRE you to buy insurers' over priced, shoddy product.
01-08-2010, 04:54 PM
Good news! It looks like the PS we want to consult with IS in network!! A couple ladies on here recommended Dr. Staffenberg in the Bronx. Does anyone else know about him or dealt with him? Thanks for all the replies! I am very happy to have found this site.
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