Major Setback

anonemouse · 01-31-2007, 02:00 PM

I feel like crying.:(

I just got a call from the nurse manager at my insurance company. Apparently, the surgeon I was going to have do my surgery isn't covered by them. They won't pay anything if I have it done by them. She gave me some names of other surgeons, though, so I am going to check them out. She also said that they only cover bariatric surgery at 50%, so now I will have to come up with money if I decide to still have the surgery.

ReneBean · 01-31-2007, 02:45 PM

Sorry Laurend.

That really sucks. I hope those other docs are good ones.

And I hope they have some sort of financing options for the portion not covered by insurance.

Hugs!

**Alexandra** · 01-31-2007, 02:57 PM

Oh, Laurend, how frustrating! Fingers crossed for you that it works out well, and SOON!!

tann · 01-31-2007, 03:07 PM

:hug:

anonemouse · 01-31-2007, 03:19 PM

Well, I found out from the nurse manager that there are only 3 approved surgeons in the Tennessee/Kentucky area. The one in Kentucky only does RNY, so he's out. There is one in Knoxville, TN that I have called to get rates. There is also one in Memphis. Either one wouldn't be bad, I think. Knoxville is an hour from my parent's house, and my brother lives in Memphis, so I would be able to stay with someone after surgery. The one in Knoxville is much closer to where I am in Kentucky, but he isn't as experienced as the one in Memphis (at least, according to OH).

lisah25 · 01-31-2007, 03:28 PM

That is sucky! I hope you get something good figured out.

anonemouse · 01-31-2007, 05:01 PM

Well, I think I am going to go with the one in Memphis. It is much further away than the one in Knoxville, and the surgery costs more, but she is alo much more experienced. Maybe this has been a blessing in disguise. The surgeon I was originally going to have wasn't really that experienced with lap-bands. The new one has done well over 100.

gentlespirit · 01-31-2007, 05:09 PM

Experience IS really important...hope everything goes well for you!

Emily

oneflew · 02-01-2007, 08:08 PM

Good luck Laurend! Glad it's working out for you!
sam

Wheetsin · 02-01-2007, 08:46 PM

Hi Laurend, are there any considerations around the 50% coverage? Meaning -- if you went to a surgeon who charged $100,000, and a surgeon who charged $5,000, would they pay half of either regardless? Or is the 50% capped by some amount?

anonemouse · 02-01-2007, 09:01 PM

Quote:

Hi Laurend, are there any considerations around the 50% coverage? Meaning -- if you went to a surgeon who charged $100,000, and a surgeon who charged $5,000, would they pay half of either regardless? Or is the 50% capped by some amount?

I don't know. I need to call the nurse manager back, because I have some other questions, too. I am not sure whether the 50% I have to pay is 50% of the original price ($18,000 in Memphis) or 50% of what the insurance winds up paying (since they usually pay much less than what the original bill was). That could make a huge difference. If I have to pay 50% of the $18,000, I'll have to get a loan or liquidate some stock. To top it off, I don't know if the $18,000 includes the anesthetist and hospital price or if it is just the surgeon's price.

ousooner · 02-01-2007, 09:14 PM

Sorry your going through this. Trying to play by the insurance company rules really sucks. I wish you the best.

anonemouse · 02-01-2007, 09:20 PM

Thanks! I think I'll need it!

Wheetsin · 02-01-2007, 09:32 PM

Quote:

I don't know. I need to call the nurse manager back, because I have some other questions, too. I am not sure whether the 50% I have to pay is 50% of the original price ($18,000 in Memphis) or 50% of what the insurance winds up paying (since they usually pay much less than what the original bill was). That could make a huge difference. If I have to pay 50% of the $18,000, I'll have to get a loan or liquidate some stock. To top it off, I don't know if the $18,000 includes the anesthetist and hospital price or if it is just the surgeon's price.

That's along the same lines as what I was thinking. If they pay 50% regardless, then perhaps you could have some leverage for negotiation - e.g. I could have this done for $40,000 and you'd have to pay $20,000, but I'm willing to go to this place that charges $9,000...

And usually when there's a percentage pay involved, it's a percentage of what the insurance company is billed. So if 50% is an in-network rate, you pay 50% of the network negotiated charges. If that's the case, you could be looking at a very reasonable out-of-pocket in the neighborhood of $500 - $1000. (the network negotiated amount for my surgery ended up being something like $1600 ... it makes a BIG difference what 50% they're talking about!)

But do check, an insurance expert I am not.

Sugarbear · 02-01-2007, 09:41 PM

Quote:

Originally Posted by laurend

I don't know. I need to call the nurse manager back, because I have some other questions, too. I am not sure whether the 50% I have to pay is 50% of the original price ($18,000 in Memphis) or 50% of what the insurance winds up paying (since they usually pay much less than what the original bill was). That could make a huge difference. If I have to pay 50% of the $18,000, I'll have to get a loan or liquidate some stock. To top it off, I don't know if the $18,000 includes the anesthetist and hospital price or if it is just the surgeon's price.

My insurance also only pays 50%. I will have to pay50% of what is allowed by insurance. I have AR Blue Cross Blue Shield.