INSUARANCE COMPANY HELP!!!!

TulsaMomof3

Has anyone had success getting the insuarance company to approve an out of network doctor as "In Network"? There are only 3 PS in my network and 1 doesn't do immediate reconstruction, 1 doesn't do the TRAM - which I am scheduled for, and the 3rd can not see me till the end of May. So my BC surgeon says that waiting till May is not an option for me sooooo she is writing a letter to my insuarcne company asking for an acception since there is not a PS in network to do the surgery. The PS she wants me to use can fit me in on the 22nd of May.


Has anyone goptten thier insuarance company to approve an out of network doctor under in network coverage????

TulsaMomof3

oops I meant he can fit me
oops I meant he can fit me on April 22nd

debbie1162

I know how you feel.....
Good Luck with the insurance company. I will keep you in my prayers that all will go well.

katznc

Out of network coverage
It does depend on your insurance company. Some will do it if you can prove that there was not a surgeon available that could do the procedure and that is the procedure you needed. You are covered under the Federal Womans Health and Cancer Act of 1998 for any reconstruction at any time. Unfortunatly the timing is the issue in a different way. There are limitations on what kind of PS each person can have. Your fight will be in that that is the procedure you are limited to. Helpful that the BC surgeon is writing the letter. Good Luck with your surgery and the insurance co.

cindycflynn

I would think
That the insurance company will do it IF the out-of-network surgeon will accept the same terms that they would if they were under contract. It may be more an issue of the doctor not accepting the insurance company terms. If your surgeon knows this PS, maybe she could talk to him/her about that.

I hope you can get it worked out. It's so stressful just dealing with the medical issues, it sucks to have insurance issues on top of it all.

HUGZ
Cindy

New Flower

cindycflynn said:

I would think
That the insurance company will do it IF the out-of-network surgeon will accept the same terms that they would if they were under contract. It may be more an issue of the doctor not accepting the insurance company terms. If your surgeon knows this PS, maybe she could talk to him/her about that.

I hope you can get it worked out. It's so stressful just dealing with the medical issues, it sucks to have insurance issues on top of it all.

HUGZ
Cindy

My doctors went out of the contract during my treatment
and I had to deal with out-of-network situation after my surgery for about 12 months. It is not fun!!!. You can try and ask your breast surgeon to write a letter of medical necessity and insist that in your medical conditions you cannot wait until May. I wish you luck in fighting with your insurance.
For some reason my insurance paid less out-network providers plus hospital and doctors' offices wanted payment in full and did not accepted "negotiated price". If I had to decide today I would not mess with it. It is very stressful and you can do reconstruction later even it is sounds awful.
New Flower

mariam_11_09

Years ago (about 10), I had
Years ago (about 10), I had to see an out-of-network doctor for an emergency procedure while I was on an HMO. It was all taken care of. I never saw the bill or had to deal with anything. That might have been because it was an emergency.

However I do think it depends on the health insurance as well as the medical necessity of it.

roseann4

mariam_11_09 said:

Years ago (about 10), I had
Years ago (about 10), I had to see an out-of-network doctor for an emergency procedure while I was on an HMO. It was all taken care of. I never saw the bill or had to deal with anything. That might have been because it was an emergency.

However I do think it depends on the health insurance as well as the medical necessity of it.

Only in emergency situations.
Unless it is an emergency, insurance companies not generally approve an out of network doctor as an in network. They negotiate the rates with the in network providers. Unless your doctor will accept the in network price and become a provider, you will most likely have that out of network fee. I had the OncoTypeDX test done. Blue Cross in my state considers them out of network even though there is only one place in the world that does it. The total cost was 3,000 and my carrier only paid 1,000 of it. I protested it and they paid another 800. I am responsible for the rest. They blamed it on the provider saying that the lab would not accept the negotiated rate. Good luck.

Roseann

AMomNETN

See if your company has a
See if your company has a case manager system. I have one and she is very helpful with the ends and outs. Insurance is a pain.