Author Topic: Out-of-network approval from EmblemHealth GHI (NYC)?  (Read 3129 times)

schwa

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Out-of-network approval from EmblemHealth GHI (NYC)?
« on: March 18, 2016, 01:49:48 pm »
I'm curious if anyone has had luck getting EmblemHealth GHI to grant an out-of-network exception for a surgeon who always works in a team with an in-network surgeon.  I'm probably going to have my surgery at either NYU or Memorial Sloan Kettering, and both hospitals themselves take GHI, but...

At NYU, the neurotologist takes my insurance, but the neurosurgeon he works with doesn't.  At MSK, it's vice versa.  So, either way, I'll need an out-of-network exception for one surgeon.  So far, all I know is that GHI "sometimes" grants exceptions.  We'll do everything we can to make our case, of course, but it would really calm me down if any of you had success with this with GHI.

Blood from a stone?

Thanks!
March 2016: Left 1.1cm AN diagnosed (age 39).
May 2016: Retrosigmoid @ USC Keck.
June 2016: Surgical site infection, bacterial meningitis & seizure. Surgery to remove titanium plate and wash out brain @ Jersey City Medical Center.
Now: Healthy but tired, working on stamina & vision.

oh, now what

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I had surgery 4/13/16 at St. Vincent Hospital, great surgeons from House, wonderful anesthesiologist from?  pathologist from? fantastic internist Dr. Stefan,  geat care at St. Vincent, previous consult at House was paid as in-network. I have appealed to have all providers considered in-network as an in-network team with VAST experience could not be found in network. Also, one surgeon was considered an assistant and paid $300, even though the surgeons have different specialties. My appeal will be considered July 11, a 10 minute meeting allowed.  I plan to go. Anyone with any experiences they can share? I was told in a phone conversation with the insurance co. I would have to meet out-of-network maximum or in-network out of pocket maximum, not both. Now I am going to be asked to meet both, OUCH. Hope these treatments don't create financial events from which people do not recover.
midfossa Wilkinson, Schwartz, Basta, Roberts @ House 4/13/2016, sticky 1.2 x 0.7 x 0.8, no pain ever, facial nerve preserved (camera cannot tell any difference) hearing not, age 64, walking 2 miles daily unless lightning, heat or ice--if you can, work up to walking 2 miles per day, the magic pill

michellef08

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Re: Out-of-network approval from EmblemHealth GHI (NYC)?
« Reply #2 on: June 27, 2016, 07:58:43 am »
I didn't have EmblemHealth, I had Aetna but was in the same position a few years ago. One surgeon and the hospital was "in-network" but the other surgeon was "out-of-network".  It took a million (stressful) calls to my insurance company, and also House Clinic (where I had my surgery done). I finally got through to the surgeon's actual assistant, who magically said everything would be covered in-network. I'm pretty sure the surgeons can elect to take the "out-of-network" rate from the insurance company (they get paid less) but you pay the "in-network" rate if they decide this. Good luck!
Diagnosed Dec 2012: AN right side 1.4 cm with mild hearing loss and tinnitus. Surgery: Middle Fossa at House with Schwartz/Friedman on April 10, 2013. Entire tumor removed, no facial issues, no balance issues, and they preserved my hearing!!

oh, now what

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Re: Out-of-network approval from EmblemHealth GHI (NYC)?
« Reply #3 on: June 28, 2016, 04:08:39 pm »
Thanks, I see this will be another challenge. Generally I am finding phone coversations with insurance companies worthless -- document, document, document. I am happy I had a great place to go for treatment, and a way to get there, and am feeling well enough to start to handle this, just have to shake this fatigue. I will have to get someone to go with me to this insurance co. meeting, I think it's best to never go alone.
midfossa Wilkinson, Schwartz, Basta, Roberts @ House 4/13/2016, sticky 1.2 x 0.7 x 0.8, no pain ever, facial nerve preserved (camera cannot tell any difference) hearing not, age 64, walking 2 miles daily unless lightning, heat or ice--if you can, work up to walking 2 miles per day, the magic pill

sdima2424

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Re: Out-of-network approval from EmblemHealth GHI (NYC)?
« Reply #4 on: September 20, 2016, 01:00:32 pm »
does any one know what the doctor cost is for surgery  with out insurance  average 

 


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