Insurance questions

[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.

Also in the chat I asked the agent to check the coverage on the codes my doctor sent me and they replied with the following :

It going to fall under your surgery benefits
and pt code 54405 will require a
authorization.
Surgery Outpatient Institutional Benefits
In Network: (then it went onto my plan percentages and all that )
This is a covered benefit on this policy,
based on medical necessity.
There are no visit limits for this service.
A preauthorization may be required for
this service depending on the procedure

What can I infer from this? And is there anything else I should do?

[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 contacted my insurance company and I received all the codes from my doctor and asked the insurance company about coverage on them and they said the following

It going to fall under your surgery benefits
and pt code 54405 will require a
authorization.
Surgery Outpatient Institutional Benefits
In Network: (then it went onto my plan percentages and all that )
This is a covered benefit on this policy,
based on medical necessity.
There are no visit limits for this service.
A preauthorization may be required for
this service depending on the procedure

What can I infer from this? And is there anything I should do?

[Lost Sheep]

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.

Male fertility is one thing. Restoring a lost bodily function is another. The one may be excluded, but the restoration of a function is pretty much the reason for the existence of insurance. If an injury or disease rendered your hand non-functional (and it was curable with treatment or surgery) there would be no question about insurance coverage.

[iwantanewone]

Hi young……
As I mentioned in my prior post, the best thing to do is let Clavell‘s office handle it. If they get the approval and the pre-authorization… you are covered. I would not continue contacting the insurance company as you might say some thing that they want to hear and not cover your surgery. Clavell‘s office and staff are very good at this. They know all the codes and how to get everything approved. Perhaps you should contact his office and ask how the preauthorization is going. The best thing to do is stay away from the insurance company and let Clavell‘s office handle it and if it is a covered issue in your policy, they will get you approved. But, as I stated earlier, it will not hurt to delay the surgery even a month or so until the pre-authorization is in place, and then you are covered. If you have the surgery prior to preauthorization, you will absolutely be paying for this yourself…good luck!

[Floridaspeedo]

You need to let the Dr work with the insurance company. They know the codes and what to say back to them. I only worked with the insurance company to push it along but I never was involved in the codes, pre-auth, etc.

The Doc's team is experienced with that.

[Old Guy]

Have to totally agree with the last few posts, let the doctors' billing office take care of that.
Insurance and the IRS are two folks you don't want to mess with.