ANA Discussion Forum
General Category => Insurance => Topic started by: wcrimi on October 27, 2008, 06:12:21 pm
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I have Aetna HMO in New York.
My ENT stromgly recommended that I go see Dr. Kalmon Post at Mt Sinai for a consultation about my AN even though he is not in my plan. I paid him out of pocket and became convinced that he was the man to do my surgery despite seeing another qualified surgeon at NYU for another consultation (Galfinos/Roland). I then went to see another doctor that does the surgery with Dr Post (Dr Eric Smouha) who is in my plan. We set a date for surgery and tried to bring Dr Post in under Dr. Smouha, but despite a special referral from my Primary Care Doctor and a Peer to Peer review Aetna is rejecting it because they say there are other surgeons at Mt Sinai that can do the procedure besides Dr Post. Of course there are, but IMO none will give me the same chance of retaining my hearing or are as experienced etc...
I was told to try a member review next. I have no idea how to do that, but will try to find out tomorrow.
What I just want is for Aetna to cover an amount for Dr. Post that is EQUAL to the amount they would be willing to cover if I used an in plan doctor. I am willing to pay Dr. Post out of pocket for the rest because I realize I am going out of plan. I'm not being greedy. I just want what Aetna is already willing to pay, I just want to use my own choice of doctors.
If anyone can help me in any way, shape, or form I would strongly appreciate it because my surgery date is 11/6 and I have already begun some of my pre op tests. Than you.
By the way, I would have had the same problem with Dr Galfinos because Dr. Roland is not in my plan. I have heard that those guys have been able to work things out with Aetna some of the time. So I am not sure what the problem is.
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I had the same problem when I had my surgery with the same insurance company and they were relelentless. Dr. Smouha was not my doc altough I did see him for a second opinion and he seemed like a really fine doctor. iI knew he I knew Klamon Post was there too, but that he did not accept insurance and did not even try to see him for that reason, although my doc recommended Joshua Bederson, chairman of neurosurgery, who also doesn't accept insurance. I went with Dr. Chun Chen, a colleague recommended by Dr. Bederson. Dr. Chen was described as a brilliant surgeon by both , drs to me. My hearing was already lost prior to surgery but I had no other complications other than a slight balance problem. I am srue Dr. Smouha must know Dr. Chen, but if you are interested in his phone # PM me and I will provide it.
Best wishes in your fight with Aetna,
Wendy
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P.S.
I assume you have no out-of-network coverage as part of your plan. The one thing I didn't try was adding out-of-network coverage because my husband felt it was too cost prohibitive. Since you are willing to pay Dr. Post out-of-pocket for the difference, you might be willing to pay for this coverage too, if Aetna is willing to let you add it to your existing policy.
Wishing you good luck again,
Wendy
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I thought about trying to add some out of network coverage, but it is much more expensive, I'll still out of network costs, and the insurance costs will accumulate over time. At this late date I am not even sure if that is feasible. My surgery is scehduled for next Thursday and I really don't want to delay it or complicate matters further.
Dr. Chen was recommeded to me by Aetna through my GP, but I don't know anything about him and he doesn't seem nearly as experienced as some of the other doctors I went to for consultations. Not saying he isn't great, but I don't know that. Even if I switched, the date would probably have to be moved and I have already done all the pre-op tests other than a cat scan. THat could cause another series of problems.
I may see my congressman and call the state insurance board as well while trying to fight this further myself for at least some coverage.
It's INSANE that they won't give me an amount equal to that they would be willing to pay Dr. Chen so I can see the surgeon of my choice. It costs them nothing extra and would make me happier.
Just to make sure, Dr. Chen is also at Mt Sinai correct?
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Yess, Dr. Chen is also at Mt. Sinai. I know his office is in the same building as Dr. Smouha. I can't remember his office is either on the 7th floor or 8th floor. I know Dr. Smouha is on one of these floors too, so whichever one Dr. Smouha is not on is where Dr. Chen is. I think he also works with Dr. Bederson's wife doing Novalis (I can't remember her name). Dr. Chen may not be quite as experienced with ANs as Dr. Post, but is very good. I know you don't want to change your surgery date and I hope you don't have to. You can try the NY State Department of Insurance if you want to, but I've had dealings with them. If they feel you are right they are very effective ally but move slowly, I'm sure they have thousands of complaints. Even if they rulesd in your favor, it probably wouldn't happen before November 6. It's certainly worth a try though.
Best wishes,
Wendy
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Another P.S. I was searching for the statement I got from Aetna regarding Dr. Chen's bill. I don't remember what he charged, but I know Aetna paid him $9,000 +, not even close to what he billed. I was thankful not to have to pay the balance. I'm not saying you shouldn't have the doctor you want, just letting y ou know how big a difference you will have to pay if you do. FYI , when I was fighting with them, Dr. Bederson was willing to take whatever their out-of-network fees were too and it didn't make a difference to them.
Cheering you on,
Wendy
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One last thing, Dr. Chen was written up in New York Magazine a few months ago as one of the top neurosurgeons in New York. Just thought you should know since this also might make you feel better.
Wendy
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Thanks everyone. I am still fighting, but it doesn't look good. I filed a personal appeal and will probably call the state insurance board next week. In the mean time, Dr. Post as agreed to do it for 10K, which will be painful, but I can tolerate it. Unfortunately, I'm having a slight problem with my pre op tests and unless I can get that resolved quickly (going to see a hemotologist today) the surgery may be delayed anyway.
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Good luck with your pre-op test results -- hope everything woprks out and you don't have to delay your surgery. $10,000 is a lot of money but if what Dr. Chen billed the insurance company is any indication Dr. Post probably cut his fee by 2/3.
Wendy
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Thanks for the help Wendy. I was told Dr. Post normally charges 23K. Went to the hemotologist today and also had my Cat Scan. I'll find out on Tuesday if I can go forward.
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Good luck and keep iin touch. I'll look forward to seeing how your surgery goes next week (hopefully) and hope you have someone who will post for you. If I can help in any way, let me know. You will be in my thoughts and I'm crossing my fingers for you that the hemotologist gives his/her okay.
Best wishes,
Wendy
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Wendy,
Assuming a good result, how long do you think it will take before I'll be able to post here on my own. ???
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It all depends on how you are feeling after surgery. I had an excellent outcome and hope you will too, but everyone's experience is different so I can't make any predictions. If you have no problem with naseua and no other major problems, you could be posting yourself farily soon. My surgery was on July 25 and I was in NICU until July 27 -- I was moved to a private room in 8 West that day. By that afternoon, I was posting from my husband's Blackberry.
I also wanted to let you know that the nurses in NIUC are wonderful. I only remember one of them by name, his name was Matthew and he was terrific. I found htem very compassionate and attentive. The nurses in the stepdown unit (8 West) were fantastic too, and I remember quite a few of them, Peggy, Joy, Olivia, Olga or Uma (Iforget) Regina and others who's names I can't recall. They were all angels. I really thought they had a calling to their profession. You will be in good hands.
When you start walking around there is a day room with a snack and soda machine and TV. It's a good place to go just to get out of your room, even if you don't want anything. The day room by the neurosurgery step down unit is kind of dark, but if you walk across the bridge, past the elevators and the ENT unit, the day room near the orthopedic unit is much nicer, big windowsto look out and brighten the room and better magazines to look at too.
I hope reading this all helps make you a little more comfortable. Feel free to contact me again.
Wendy
Wendy
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Wendy,
I was just looking at some notes about your experience and it says that your AN was 1.3CM at diagnosis and 2CM at surgery with only a couple of months in between. Do they think the original size diagnosis was wrong or did it actually grow that much so quickly? I read that they usually only grow 2mm per year.
I can't tell you how much I appreciate the tips and comfort you are giving me. I'm feeling kind of anxious between all the stresses of insurance issues, pre opt test, and the surgery itself.
Hopefully, my last pre opt test will be OK. A hemotologist is looking at my blood again because it was a little thin on the first test. If it's OK, I guess all systems are go.
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Wayne,
I answered your last post by PM -- don't know if you saw it but hopefully you did. I'm crossing my fingers for you that everything will be a go on Thursday.
Best wishes,
Wendy
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Hi Wayne,
Hope you get the green light from the hemotologist. Let me know what happens.
Wendy
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Wayne -
I've been wondering too if your surgery is on for Thursday.
Hope everything has been straightened out.
Jan
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I am having my surgery tomorrow 11/6/2008 at Mt. Sinai Hospital in NY ay 8:00 AM.
I didn't find out until late this afternoon when the blood test results finally came in.
Wish me luck.
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Wayne:
Thanks for the update. Not much time to worry, is there? This might be a good thing. In any case, you have my hopes and prayers for a successful, trouble-free surgery and a smooth recovery. Post when you can.
Jim
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Good luck, Wayne.
See you as a postie ;D
Jan
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I wanted to update this thread because I may have gotten some good news today that can help others down the line.
I wound up paying Dr. Post out of pocket for my surgery, but I continued fighting Aetna all these months until all my appeals were exhausted. I even had letters from Dr. Post, Dr. Smouha, and Dr Etra (my ENT) on my behalf. When Atena rejected every last appeal, I called the NYS Insurance Dept. I forwarded all my documention and letters to them. I was told today that Aetna has reversed their opinion and I will be compensated. They are going to consider Dr. Post as part of a team (or something like that) with Dr Smouha who is in my plan. I am probably unlikely to get the full amount, but at this point anything I get is a plus because I was already convinced I had lost and only followed through because I felt I deserved something. I wasn't asking for full compensation. I was only asking for what they would have been willing to pay an in plan doctor. I felt I deserved some extra flexibity because of the type of surgery, my good chances of hearing retention, and my need for hearing to do my job.
When I find out what I am going to get, I'll let everyone know.
The good news is that it's not impossible to win one of these appeals if you do all the work and make a good case.
Wayne
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Hey, hey, that's a great success story, Wayne! As you say, it is not impossible, and dogged persistence can pay off in the end. Nice work!
Steve
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Wayne, Hi! Thank you so much for posting this update! I have been thru ins. company reviews (when my daughter had a car accident), but never had to go to the State level (and really don't know how.) But if i ever need to, i will learn how!
This information is good to know!
Ditto what Steve said!
I think when you have paid all the insurance premiums and have a more unusual condition, the ins. can 'bend, alittle more!
Take care,
Sue
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HI WAyne,
That is awesome news. I have been on the phone all morning with insurance company trying to figure out how I'm going to pay for all this. I've seen Dr. Selesnick, Steig and Dr. Post so far and all are out of network....as for the surgery which I'd like to get done who knows how much I'm going to be in debt for.
My insurance company is GHI and BC/BS but none of the doctors that i'm even interested in are in this plan. I don't want to go to any doc to perform Brain surgery. My hearing is 100% right now and they are recommending the Mid Fossa and say I should have 60-75% hearing preservation. Problem Dr. Post does not perform this procedure, Not sure about Selesnick but either way he is out of network too. I don't know what to do? So your news about fighting it and at least getting some covered is very encouraging. Please keep me updated.
FRUSTRATED AND CONFUSED!!!!!
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Wayne ~
Congratulations on your victory...and, make no mistake, it really is a victory.
I've found that appealing to the state insurance commissioner when your insurance company 'stonewalls' your seemingly legitimate claim can have a very positive effect on subsequent claim payment decisions by the company. My wife and I have been down this road, too. The reaction from the insurance company is usually rapid but they never admit they were wrong. No matter, as long as the bills get paid. Even if you don't receive 100% of what you've laid out in payments, you'll certainly get more than you would have had you simply shrugged and 'walked away'.
Your case is a credible lesson to others in similar situations. Prepare, know your facts (the policy limitations and exclusions) and be tenacious . You, too, can be victorious over the parsimonious insurance company.
Jim
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Dawn,
I don't the know the specifics of GHI, but I exhausted all my appeals both before and after surgery at Aetna before I went to the state insurance board.
I basically made the case that I wanted to go out of network because DR. Post gave me a better chance of hearing preservation than the IN PLAN alternative they suggested and hearing was important to my job. I also noted Dr. Post's vast experience with AN surgery relative to most other doctors that could do the procedure, the fact that many of the "in plan" doctors worked with other surgeons that were not in plan so I would be right back where I started if I went to an alternative (I also consulted with DR. Galfinos at NYU who is in my plan, but his partner Dr. Roland was not), and told them that Dr. Smouha often worked Dr Post as a team and Dr. Smouha was IN PLAN. I even had letters from my ENT, Dr. Post and Dr. Smouha saying all the same things. They rejected me at every point.
The state insurance guy was hardly interested in all the letters I wrote, my hearing test results, MRI reports or my whole story. All he wanted was copies of the doctor's letters and everything that Aetna had ever sent to me rejecting my appeals. I guess he was a lot more powerful than I am because they changed their tune quickly. I did a lot of work to win this fight. It was very stressful before the surgery and I borrowed money to pay Dr. Post that I will now hopefully be able to pay back quickly. But I also have to thank all my doctors for giving me letters to support my cause. That apparently is the key.
Feel free to ask me any questions as you move through the process and don't be afraid to ask an out of network doctor for a small break in the fee if money is an issue (and it is for almost everyone). Dr. Post was very good about that and Mt Sinai was willing to work out an extended playment plan if I couldn't come up with the cash. I'm sure there are other doctors like that.
Also, check is Dr. Galfinos is in you plan. He seemed like a terrific guy also.
You can contact me privately if you would like.
Wayne