Insurance questions

[Gt1956]

Warning on rescheduling. Its my understanding that an approval is only good for that procedure on that date. If the date is chsnged then you stand a good chance of needing a new approval unless the insurance is willing to change the date. Not a guarantee that they'll do that promtly.
Afterall, they budget this stuff to fit their cash flow. Much like placing your bills in order to pay them. They have accountants that monitor those things.
I had a dr explain this to me when insurance denied coverage for one of my wife's surgeries. He said that upon resubmitting it they'd approve it. I asked why. He said if their budget is tight at that date. They tend to just deny what they think can wait. He was correct. It was approved on the second submission. Obvoiusly at a couple of weeks later date.

[Youngdeadpeener]

Hi Young,

The best thing to do is to reschedule the surgery. Dr Clavell and his team know exactly how to get insurance approved and if your insurance is going to pay, they will get it. However, if you proceed with the surgery without having prior authorization and everything in place they no doubt will be billing you. It seems like you should only be delayed about a couple of weeks, but it can savev you a ton of money. As stated before, you never know what can happen with these implants and if you need additional hospital stay or work or something like that it could cost you plenty. It sounds as though you probably have coverage but until you get that authorization and everything cleared, I would just sit tight. It doesn’t sound like it would be too much longer. Good luck!

Really needed to hear this, built up a lot of anxiety around the situation but I just got to hold on. Thank you

[Youngdeadpeener]

Warning on rescheduling. Its my understanding that an approval is only good for that procedure on that date. If the date is chsnged then you stand a good chance of needing a new approval unless the insurance is willing to change the date. Not a guarantee that they'll do that promtly.
Afterall, they budget this stuff to fit their cash flow. Much like placing your bills in order to pay them. They have accountants that monitor those things.
I had a dr explain this to me when insurance denied coverage for one of my wife's surgeries. He said that upon resubmitting it they'd approve it. I asked why. He said if their budget is tight at that date. They tend to just deny what they think can wait. He was correct. It was approved on the second submission. Obvoiusly at a couple of weeks later date.

I will bring this up, either way I’d have to reschedule as the person going with me has to notify their job 2 weeks in advance that they’ll be gone

[JohnHC]

My insurance pretty much has hiser me over. They told me on 3 occasions that the surgery and device are covered, they told my Dr it was covered, they told the hospital it was covered. Now I had called them personally and gave them the cpt codes which they looked up under my plan, all is ok device and surgery covered, then just before my revision ( just over 2 months after my first surgery ) I get a EOB in the mail that says the surgery isn't covered because it's in my "exclusions". Uhh I never got a booklet explaining I had exclusions, and I also called to confirm coverage so their system should have flagged it as excluded. But nope, so now I'm on the hook to the tune of about 150k or more for both surgeries ( I think the first was around 86k for the device and hospital, does not include anesthesia or my Dr's charges.) So yeah watch your insurance, I would ask that they send you a letter stating that it's covered beforehand just so you have it for proof in case they later balk, I didn't and I'm hosed ( but I do have it implanted just probably get sued for non payment )

[Gt1956]

I have found that when you talk to health insurance company on the phone. You NEED to ask for the session number. They might call a different name. But I'm sure that they all do it.
If they try to suck backwards or deny that the conversation ever occured? You give them that number. Normally anything that they tell you over the phone is recorded. That is about the only way that you can hold their feet to the fire. If a representive of the company said that you have coverage? Then they'll have a harder time getting out of it.
JohnHC, that really sucks big time. See if your dr or the hospital has any written record of the approval. If all else fails. Try negotiating down to the cash price & most likely you'll have to borrow it unless you have that much laying around.
Turn over every rock that you find looking for help/clues. Good luck.

[Lost Sheep]

My insurance pretty much has hiser me over. They told me on 3 occasions that the surgery and device are covered, they told my Dr it was covered, they told the hospital it was covered. Now I had called them personally and gave them the cpt codes which they looked up under my plan, all is ok device and surgery covered, then just before my revision ( just over 2 months after my first surgery ) I get a EOB in the mail that says the surgery isn't covered because it's in my "exclusions". Uhh I never got a booklet explaining I had exclusions, and I also called to confirm coverage so their system should have flagged it as excluded. But nope, so now I'm on the hook to the tune of about 150k or more for both surgeries ( I think the first was around 86k for the device and hospital, does not include anesthesia or my Dr's charges.) So yeah watch your insurance, I would ask that they send you a letter stating that it's covered beforehand just so you have it for proof in case they later balk, I didn't and I'm hosed ( but I do have it implanted just probably get sued for non payment )

In addition to GT1956's advice, look into your insurance company's appeal process, ask for the exclusion list (hopefully it will have the CPT codes (whatever they are, they are supposed to be a code identifying what medical procedure you are having). CPT codes identify what is covered and what is not to the computers and bean counters and some procedures have an overall code which is excluded, but if you look up the codes for the individual procedures that make up the overall procedure, they are not excluded. Your doctor's billing office should be well-versed in that esoteric part of our medical "care" system.

Consult a lawyer. Initial consult should be cheap for the advice you will get.

[Youngdeadpeener]

My insurance pretty much has hiser me over. They told me on 3 occasions that the surgery and device are covered, they told my Dr it was covered, they told the hospital it was covered. Now I had called them personally and gave them the cpt codes which they looked up under my plan, all is ok device and surgery covered, then just before my revision ( just over 2 months after my first surgery ) I get a EOB in the mail that says the surgery isn't covered because it's in my "exclusions". Uhh I never got a booklet explaining I had exclusions, and I also called to confirm coverage so their system should have flagged it as excluded. But nope, so now I'm on the hook to the tune of about 150k or more for both surgeries ( I think the first was around 86k for the device and hospital, does not include anesthesia or my Dr's charges.) So yeah watch your insurance, I would ask that they send you a letter stating that it's covered beforehand just so you have it for proof in case they later balk, I didn't and I'm hosed ( but I do have it implanted just probably get sued for non payment )

So the insurance company itself had it excluded or your employer had it excluded which the insurance company later notified you on?

[Youngdeadpeener]

My insurance pretty much has hiser me over. They told me on 3 occasions that the surgery and device are covered, they told my Dr it was covered, they told the hospital it was covered. Now I had called them personally and gave them the cpt codes which they looked up under my plan, all is ok device and surgery covered, then just before my revision ( just over 2 months after my first surgery ) I get a EOB in the mail that says the surgery isn't covered because it's in my "exclusions". Uhh I never got a booklet explaining I had exclusions, and I also called to confirm coverage so their system should have flagged it as excluded. But nope, so now I'm on the hook to the tune of about 150k or more for both surgeries ( I think the first was around 86k for the device and hospital, does not include anesthesia or my Dr's charges.) So yeah watch your insurance, I would ask that they send you a letter stating that it's covered beforehand just so you have it for proof in case they later balk, I didn't and I'm hosed ( but I do have it implanted just probably get sued for non payment )

In addition to GT1956's advice, look into your insurance company's appeal process, ask for the exclusion list (hopefully it will have the CPT codes (whatever they are, they are supposed to be a code identifying what medical procedure you are having). CPT codes identify what is covered and what is not to the computers and bean counters and some procedures have an overall code which is excluded, but if you look up the codes for the individual procedures that make up the overall procedure, they are not excluded. Your doctor's billing office should be well-versed in that esoteric part of our medical "care" system.

Consult a lawyer. Initial consult should be cheap for the advice you will get.

Hey so I received my Cpt codes and diagnosis code , I contacted the insurance company and they said I had to reach out to my dads employer for the benefits booklet which I did and I’m in process of getting that . Dr clavell already sent a pre authorization request to my insurance company. Should I still call my insurance company and ask if those Cpt codes with the diagnosis are covered even though he submitted the request?

[JohnHC]

Young...... I believe the insurance had it excluded, I'm on a high pay/high deductible plan and the insurance told me it was all in my handbook ( which I was never given, sent or emailed ) and I had to do some serious digging around on the insurance website to find the "book" and then dig deeper to find the exclusion list. It's excluded under male fertility procedures - basically anything that'll help you get a gal pregnant is excluded ( drugs like Viagra, Cialis, Trimix etc...) I had to pay full price for my Trimix, but at the time I was told it was because it's a "compounded" drug not because of male fertility ( lol ) they don't cover compounded drugs except in rare cases. I don't know what else is going on with my case as the hospital said they were resubmitting the charges, I only owe my Dr around $2500 or so ( according to their calculations ) and insurance hasn't sent any other EOB's yet and that's been over 2 months now. Just gonna wait and see how it plays out.
And yes even though your Dr has submitted a request I would still call and check, sometimes things get stalled and by calling it sometimes hurries the request along plus you might find out before the Dr does that it's covered which would be one less thing to worry about.

[Youngdeadpeener]

Young...... I believe the insurance had it excluded, I'm on a high pay/high deductible plan and the insurance told me it was all in my handbook ( which I was never given, sent or emailed ) and I had to do some serious digging around on the insurance website to find the "book" and then dig deeper to find the exclusion list. It's excluded under male fertility procedures - basically anything that'll help you get a gal pregnant is excluded ( drugs like Viagra, Cialis, Trimix etc...) I had to pay full price for my Trimix, but at the time I was told it was because it's a "compounded" drug not because of male fertility ( lol ) they don't cover compounded drugs except in rare cases. I don't know what else is going on with my case as the hospital said they were resubmitting the charges, I only owe my Dr around $2500 or so ( according to their calculations ) and insurance hasn't sent any other EOB's yet and that's been over 2 months now. Just gonna wait and see how it plays out.
And yes even though your Dr has submitted a request I would still call and check, sometimes things get stalled and by calling it sometimes hurries the request along plus you might find out before the Dr does that it's covered which would be one less thing to worry about.

What exactly should I ask my insurance company? This is where I’m kind of confused