dealing with insurance companies

[formula30]

I have just been recently diagnosed, I have seen the neurologist and will be seeing the ent tomorrow, I am unsure as how to proceed with my insurance.  I have been referred to Dr. Wilcox ENT, lots of experience with acoustic neuromas,  by Dr. James Evans neurologist, who also does alot of acoustic neuromas.  I have the mri brain scan w dye, and my ct scan from 2005, we are trying to decide when this may have started, it is 19mm.  Just medium size, but definitely causing me some problems.  I have Aetna HMO, Thomas Jefferson Hospital is in network, and so is Dr. James Evans, but Dr. Wilcox isn't I guess he would be considered out of network............I don't want to take a chance on someone who doesn't deal with these alot........is there something I can do, to make sure the insurance route runs smoothly, and I get things paid for, I have no problems with the extra charges for testing, or co pays, or the 3,000 for the first five days in the hospital........and I am sure there will be other incidentals, but I want to make sure that what the doctors and I decide will be accepted.  Gamma, Cyber, or retrisigmoid.......I have a lot of confidence in these people............any help so I can get the ball rolling would be great thanx again.

[Jim Scott]

Hi ~

I'm not an expert on medical insurance procedures and, of course, every insurer has their own set of rules and every state has it's own regulations for insurance companies.  This makes it difficult to offer concrete advice on insurance questions.  However, talking to your insurance company (they'll probably assign you a 'case manager') is the first step.  Explain what is happening and what your plan is.  The out-of-network doctor (Wilcox) will be paid at a lower rate (with you having to make up the difference) but sometimes, if this doctor is an expert in his field, the insurance company will negotiate and may opt to pay Dr. Wilcox at the 'in-network' rate.  It's worth trying for.  Basically, you're seeking pre-approval for treatment and that will come when you have a definite treatment plan.  The doctor's offices should be able to handle most of this for you.  Mine did.  I had Blue Cross/Blue Shield and after my initial $2,500. deductible was paid (by me), they paid for everything, including all tests, at 100%.  As you noted, a few bills will likely end up your responsibility.  I incurred some AN-related bills that I was able to pay off in monthly payments with no hassle.  I think the hospital and doctors are grateful just to get paid, considering how many folks are either under/uninsured. 

So, (with your doctors) establish a treatment plan and contact your medical insurance company to seek their approval.  You may have to 'fight' for some things.  That you're cognizant of the possibility that everything won't be covered at 100% is realistic and practical.  My experience is that many doctor's offices have people that specialize in working with insurers to 'smooth the way', as you hope.  I trust that you'll be successful in your quest for insurance coverage for whatever procedure you chose to address your AN.   

Jim    

[OTO]

Ask the doctor's office if they have an insurance coordinator or if the hospital has one.    They should be able to help you coordinate with the insurance company.  Pre-Surgery, I was able to talk to the both the coordinator and the insurance comoany, and kind of knew what to expect.   I was lucky, the clinic I went to took care of everything.  There were two or three items that took several iterations before the insurance company agreed to pay.   Everytime I got an insurance statement or a medical billing, I would call and talk to them to figure out what I actually had to pay.

[leapyrtwins]

Whatever doctor - or doctors - you ultimately pick for treatment should have a staff that will contact your insurance company.  This is pretty routine for them; just part of their job.

They can ask the coverage questions, get you pre-certified for treatment, give the insurance company the correct CPT codes, etc.

My doc's staff has dealt with everything to having my AN surgery and my annual MRIs pre-certified, to asking for and getting approval for my BAHA implant surgery.

Don't hesitate to ask your doc for his staff's assistance; that's what they are there for.

Jan

 

[jaylogs]

As was stated by everyone, the hospitals and doctors are all very good at handling these things, I guess it's in their best interests if they wanna get paid!  I have Cigna and the whole thing...minus the $20 copays for office visits, was paid for, 100%.  I was flabbergasted as the statements were rolling in afterwards, so and so would charge say $70,000 for something and my insurance paid them only a 10th of that, and I wasn't responsible for the rest...thank goodness! There were a couple of times I had to call the doctors or insurance and have them resubmit, but after that it was all good!  Anyways, like it was said, give all parties involved a call so there'll be no surprises for them. Good luck!
Jay

[formula30]

Well I have found I am very lucky, Dr. Wilcox is in network, what a relief

[jaylogs]

Wooohooo!! Way to go! See, sometimes the system really does work!
Jay