Newly diagnosed AN trying to get out of network coverage for surgery on Anthem

[mhopwood]

I live in Connecticut and have a self insured plan with Anthem Blue Cross Blue Shield.  I pay $17,000 per year out of my own pocket for this insurance and I'm starting to worry that at a time when I really need insurance, I will get screwed.  My local ENT referred me to Dr. John T. Roland from NYU Medical Center and I feel very good about his qualifications.  I have an appointment scheduled with him the week after next.  I spoke with his office and found that he does not accept Anthem BCBS.  I pulled out my policy and read it thoroughly.  The policy went into great detail about coverage for out of network providers and the cost share equations for such coverage.  It also explained that you needed pre-approval.  My wife called Anthem and they told her that our plan doesn't include coverage out of state or out of network.  I re-read my policy confirming in fact that we do have this coverage and I called a second time.  The woman on the phone again told me that my policy does not cover out of state or out of network providers.  I then began to read my policy aloud.  She had a superior look up my actual policy and finally agreed that out of state/network coverage was available with my plan but it requires pre-approval from my primary care physician.  The pre-approval request may be approved or denied.  I asked her what would be required for them to get an approval and she said that they would have to make the case that it is medically necessary for me to go to this doctor in New York versus a doctor that is in CT.

I happen to know that there is a surgeon in CT (Dr. Joseph Piepmeier) that lists Acoustic Neuroma surgery on his list of specialties.  I am attempting to learn more about him.  My local ENT told me about a group that does this in CT and the group in NY.  I asked him which ones are the experts - and he immediately suggested Dr. Roland in NY.  I don't want to go to a CT surgeon that does this only a few times a year versus the NYU surgeon that does it a few times a week.   Has anyone else out there confronted a similar battle?  Do you have any advice?  I want to make sure I'm going to the best doctor possible.

[ppearl214]

Hi welcome Sorry to hear you join our ranks but thrilled you found us!

I'm going to reference Jim Scott (also a Moderator on this site)... he is in CT, had his AN surgery in CT at St. Raphael's.  Noted below is a link to his earlier discussions on this site re: his AN journey and treatment at St. Raphael's:

http://anausa.org/forum/index.php?topic=1426.msg14786#msg14786


Jim had his large AN debulked, then the remainder irradiated (Radiation).

Jim would be a terrific resource for his AN journey done "in state" in CT.

I hope this helps... and again, welcome.
Phyl

[Jim Scott]

Mhopwood:

I had Blue Cross/Blue Shield medical insurance at the time of my diagnosis, surgery and later, radiation.  They paid most of the costs, which were well over $100,000.  I paid a little over $2,000. 'out-of-pocket'.  Here is a link to Connecticut Neurosurgery, the practice Dr. Goodrich works out of.  http://www.ct-neurosurg.com/  Their offices are physically connected to the hospital of Saint Raphael and they are 'in-network'.  For further information, send me a PM and I'll respond with whatever information I can offer that might be useful to you.

Jim

[Jill Marie]

Hello,  I had to deal with a similar situation over 17 years ago.  My doctor told me to see Dr. Mangham for my An, my Insurance said I had to see a doctor in Network that had only been doing the surgery for a year or two.  I told Dr. Mangham's office that I had to cancel my surgery, they told me not to.  His office conferred with the Hospital and anyone else involved in my surgery and they all agreed to take the out of network payment in full.  I'm very glad that happened as when the doctor examined me the day before surgery he found that I had a Facial Neuroma not an AN and the other doctor was not qualified to do that surgery.  I would love to think there are other doctors out there that will do the same.  If you are set on the doctor in NY perhaps you can get him to accept the out of network payment.  Goodluck in whichever way you go.  Jill

[lori67]

I agree with Jill.  There is usually a way to get the insurance companies to cooperate, but it takes a bit of work.

Your PCP may have to write a letter to the insurance company explaining why he wants you to go to the doctor in NY.  I remember when I was diagnosed, my PCP knew exactly what surgeon he wanted me to see and he said if my insurance didn't cover him, he'd fight them on it on my behalf.  Fortunately, he was covered, but doctors are used to this kind of stuff, unfortunately.

Keep at it and good luck!
Lori

[pjb]

I too was referred to a surgeon who was out of network and advised me not too worry they will work with the insurance company and now I am having a little problem with that they are sending large bills........... and now just waiting to see the outcome. Just make sure you have everything in writing the pre-auth. and the insurance companies approval...... I did not have anything in writing because at the time I was definitely not thinking clearly and was told they do this all the time. Please do not make that mistake and if you go to the NY surgeon who I heard was very good have their office commit to something in writing also.

Best Wishes,