Insurance Denial

[jeb6294]

Guess the Dr. sent in the paperwork cause I already got a denial from the insurance company. Is that pretty standard? Have an appointment in a week so I’ll take in the letter saying I want the Dr. to appeal on my behalf, but I’m not terribly optimistic.

Gov’t employee with GEHA insurance. Are there any insurance companies that are known to be more flexible with this sort of thing? We have Open Season the end of every year when we can switch insurance.

[Hillywilly]

What's your history look like? TBH I was shocked I received no denial whatsoever because I am 32 with no pre-existing health issues whatsoever. What I did have though was a record of MULTIPLE visits to the urologist and MULTIPLE Doppler scans as well as a lot of Mental health visits.

I guess my insurance company decided those would add up.

[Mlsyes]

I would suggest you inform GEHA that a US Government agency (Medicare) covers penile implants routinely. Medicare takes the physicians recommendation without a problem. You can argue GEHA (and any other companies providing FEHB insurance) should follow a US Government agency medical insurance policies.

[Gt1956]

Guess the Dr. sent in the paperwork cause I already got a denial from the insurance company. Is that pretty standard? Have an appointment in a week so I’ll take in the letter saying I want the Dr. to appeal on my behalf, but I’m not terribly optimistic.
Gov’t employee with GEHA insurance. Are there any insurance companies that are known to be more flexible with this sort of thing? We have Open Season the end of every year when we can switch insurance.

The nice thing about FEHB plans is the ease of moving between companies. Part of the down side is some companies are regional.
Advice is hard to give. Best method in my opinion is to really grill the insurance person for your surgeon. Be carefull, just because they got paid by a particular insurance doesn't mean that all policies written by that company will pay. Literally each group policy can vary on coverage from one to another. Even by the year.
A lot might depend on your retirement horizon. I was near retirement when my wife & I decided on an implant. I had plenty of money in my TSP to cover an implant completely. Hopefully insurance would cover at least part of it. Covid hit which made it hard to get a surgery date. By the time the Covid hospital restrictions eased I had retired & turned 65. I have Medicare & an Aetna Advantage plan. My out of pocket was $0. I did pay two doctor visit co-pays & for 3 generic prescriptions.
Hold the drs insurance people to their job or hopefully you are close to 65.
Likely not what you wanted to hear, but what I did.
Try to get the medical procedure codes from the dr. Before the next open season call all the major companies in your regional plans. Point blank ask if those codes are covered. You might have some luck searching FT for "codes" to find them. I do know that the forum has had several threads on the subject. Which codes to use have some nuances as to what fine points are covered.
Be sure that everytime you visit your dr that the two of you talk about ED. Build a history.

[squirrel]

Jeb,

As a current federal employee, I had GEHA medical and they will not cover an implant. They will not even consider an implant unless it is a transgender case. What I did find out was BCBS does cover implant surgery for men with ED. BCBS was the only plan available to me that covered the implant. Time for surgery I did not have a single problem with insurance. Look up the BCBS benefit booklet online. You can read it for your self in the implant section. I like you had to wait until open season to change from GEHA to BCBS. That April I had the surgery done. I hope this helps you. Any questions, let me know.

[Mark1974]

Jeb,

As a current federal employee, I had GEHA medical and they will not cover an implant. They will not even consider an implant unless it is a transgender case.

"We only cover penile implants for women"

What a time to be alive

[atranger]

So...had my implant 4/3. Expressed surprise to my doctor about how fast Cigna approved it and he said it was routine so long as it was done at the hospital and not their (Urology Practice) surgery center.

Got an invoice from the hospital for $45,000 two days ago...my plan booklet doesn't cover treatment for sexual dysfunction, including implants.

Spoke with the staff at the urologist practice who said she spoke with the insurance company and was told 100% covered, no pre-authorization needed...spoke with the insurance company rep who says their notes indicate that the conversation advised there was a pre-authorization needed and it would not be covered.

They're duking it out now and I hope the conversation was on a "recorded line".

[jeb6294]

Jeb,

As a current federal employee, I had GEHA medical and they will not cover an implant. They will not even consider an implant unless it is a transgender case.

"We only cover penile implants for women"

What a time to be alive

I think that’s what pisses me off the most…if I said I wanted to be a girl, they’d pay to lop it off, but they won’t pay to fix it.

[Txagq8]

Atranger - you probably know this, and take this for what it is: unsolicited advice from an old guy (67) on the internet who has fought insurance companies in the past and has dealt with fraudulent hospital billing errors and prevailed.

Don’t pay anything. If you know for certain about how much your copay would have been, it’s ok to send that to hospital to demonstrate (to them and the courts, if that becomes necessary) that you are acting in good faith even if your insurance carrier won’t. But in general, I stand clear until insurance and medical folks have finished fighting. Even if (and sometimes it has) taken over a year.

It would be fun to sue for discrimination (we won’t put implant in ED afflicted male but we will a trans female) and I think you could prevail, but it would cost you more in legal fees than the hospital bill. In Texas you could probably collect up to $10K from insurance carrier by hitting them in small claims court. The hospital isn’t off the hook, either, as they should be coordinating all the pre-authorization nonsense before they put you on table.

If everything else fails, meet in person with hospital administrator and surgeon’s billing office. Ask them what they would be charging if you were a Medicare or Medicaid patient or someone covered by a private insurance policy with whom they have a negotiated discounted fee. Tell them you might be willing to pay that in cash. When faced with having to write off a bill after installing an implant, a lot of discount shows up.

Take my implant as an example. My surgeon offered a cash price for the procedure around $18,000. The hospital, anesthiologist, AMS, surgeon, and various doctors billed $53,000. My insurance ended up paying them about $19,000 when all was said and done.

I’m sorry you’re dealing with this. I could get on a soapbox about my opinion of medical care “system” but I try not to. I will say good luck, don’t get overwhelmed, don’t act with haste, and so much shit that happens makes no sense at all.

I have never, ever had a hospital or doctor put anything derogatory on my credit report. Even after it’s gone to a third party for collection.

Did the hospital collect an estimated co-pay up front? If they did, that’s a good sign they had been in touch with your insurance c

[Gt1956]

Txagq8, all valid points. My thoughts are that the cash price represents what they need to cover what it costs. I guess you could argue that it is the average bill for the procedure.
I think that billing issues show the effectiveness of the staff of the surgeon that you've chosen. Many happy members shout praise of the surgeon but the rest of the team is almost as important.