Insurance issue

bhurx
bhurx Member Posts: 2
in Breast Cancer #1

My wife was diagnosed with breast cancer almost a year ago. Went thru a double mastectomy, chemo, and now is halfway thru radiation. The breast surgeon we chose is out of our network. And we knew this going forward (our out-of-network copays are 30%). The wife went thru the  Sentinel Biopsy procedure on 1/4/13 and the mastectomy on 2/7/2013. Bill after bill came and my insurance was covering most of the procedures because everything except for the breast surgeon was in-network.

A little over a month ago we received a denial of a $10,000 claim from the breast surgeon. The reason - "this procedure or supply is aprt of the Global Service. These charges are not eligible for seperate reimbursement". Upon questioning the insurer regarding this Global Service the  Sentinel Biopsy and the mastectomy cannot be billed in the same 3 month period(do they think the surgeon can perform the biopsy and mastectomy on the same day?)

When my wife was 1st diagnosed the surgeon was adamant that the mastectomy should be done within 3 months. The insurers' practices , if followed , would have put my wife's health in further jeopardy.

I am writting a letter of appeal. I skimmed over the Women's Health snd Cancer Rights Act and found some useful info. I'm looking for bullet points to add. Has anyone been thru this before?

Here's the kicker....the insurer told me that these charges, if billed from an in-network in the same manner as the out-of network surgeon, the $10,000 charges would be wiped off.

Any advice

 

 

 

Comments

  • New Flower
    New Flower Member Posts: 4,294
    #2
    Welcome to our community

    I am very sorry for your wife cancer and situation with insurance.

    In some way i had a similar situation - hospital and surgeon did not renew a contract with insurance and had become out-off network. It took several months to sort it out. I have and sentinel node biopsy   as a part of mastectomy, I do not know about 3 months rule, which your insurance is referring to.    I do know that  In-network providers must except reimbursement from insurance under the contract and that is why $10,000 could be wipe off according to an agreement between these two parties. When you go to out-off network, your provider has no obligations to the insurance company. what I am trying to say that in some instances insurance will deny services regardless of in-or out network situation. 

    I hope your appeal will be granted, however I recommend to talk to the surgeon office. Please try negotiate with the surgeon, while waiting for decision from your insurance. Do not feel shy to contact your doctor directly. It did help me.


    Good luck and let us know about outcome.  

    New Flower

     

  • desertgirl947
    desertgirl947 Member Posts: 653 Member
    #3
    See a Cancer Navigator (or

    See a Cancer Navigator (or whatever other name these people have).  That is a person my hospital has that can help with so many things that we face.  If I recall from my talk with mine (last year), if I were to have the challenges you face, I would contact my Cancer Navigator.  Aside from insurance helps, I would have leads to groups or organizations that would help me.

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