Major Setback

[Lap_dancer 8]

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.

A big hug your way and rest easy. Remember this word, "Synchronicity". Look it up. I live by it.

I'll make this brief by telling you that I discovered through research during my Appeals process, that my surgeon had done very few Lap Bands. By requiring a Center of Excellence, it will only assure a more experienced physician who has treats patients who primarily are obese. They also must undergo what I would call an "internship" of X number of surgeries before they are given the seal. It's only for an extra measure of safety IMHO.

[anonemouse 1]

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.

The original surgeon's office told me that my maximum out-of-pocket would be $2000. I don't know whether to trust that, though, since they failed to find out that the surgeon wasn't in-network. If that's true, I won't have to liquidate stock or get financing, because I would have enough to pay that out of my savings. If I have to pay more than $5000-$6000, I'll have to go into debt.

[Lap_dancer 8]

Quote:

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.

The original surgeon's office told me that my maximum out-of-pocket would be $2000. I don't know whether to trust that, though, since they failed to find out that the surgeon wasn't in-network. If that's true, I won't have to liquidate stock or get financing, because I would have enough to pay that out of my savings. If I have to pay more than $5000-$6000, I'll have to go into debt.

__________________

Most definately talk dollars and cents. Definately talk about the cost difference and savings. Never hurts to ask!!

[derbygirl 0]

Hey, consider yourself fortunate. Lots of companies aren't covering 1%.