Insurance questions

[Youngdeadpeener]

So I about two days ago I scheduled an implant with Dr. clavell for early October as that was the nearest date available. The only thing I’m worried about is that he said my insurance covers it but they need authorization. I have bcbs anthem ppo wi if that matters. I messaged the insurance company and they said they estimate they’d have an answer on the 28th of sep which is like 3 days before I’d have to leave to Houston for the surgery . Now I’m wondering if I should reschedule the surgery to another date which is about a month after my original date incase insurance doesn’t cover it . I will be having my father go with me to Houston (crazy I know but I’m pretty close with my dad ) so he needs to know when to call off . Or could I possibly finance this surgery and let’s say insurance does end up covering it will they just reimburse me for it ? I’m not really familiar with how insurance works so if this comes off as a dumb question my bad. Also what’s your experience with Bcbs anthem ppo and their pre authorization if you have it? Did they end up covering it?

[newbie443]

I had a BCBS EPO plan. That was exclusive provider and I had to go in part of my home state. PPO or preferred provider I guess is a bit different, but insurance is state controlled, and they like to keep this in state, and they seem to really dislike paying for this in my experience. In my case I could only go to doctors in part of my state to be covered. Not sure if you are in Texas or out of state. Some have posted they did get an initial approval and had it later refused. Others had it go through. Have you contacted your doctor's office about this? They deal with the insurance companies a lot and maybe they can help or give you some insight on if your state insurance pays them for this. Some doctors' offices are better than others in knowing how to get through the red tape for coverage. Others not so much.

I did find this on line about PPO insurance:

If you have a PPO plan, you may have health insurance coverage for medical care outside of your home state12. However, any non-emergency care received outside of your home state is typically not classified as ‘in-network’ and does not abide by your standard coverage or a set co-pay rates3. Only multi-state plans cover you outside of your state4. HMOs and EPOs don’t cover non-emergency out-of-network care

Your doctors business office insurance section should be able to give you an idea if you have higher co pays by going to them. And if they have been paid by the policy you have.

[Hrc714]

Insurance coverage and approval are separate things. My insurance would cover implementation but it was several cycles of proving I had exhausted all other forms of treatment before they would authorize. My initial surgery was postponed by Dr twice before the approval was granted.

[Old Guy]

You are pretty much at the insurance company's mercy. If they feel like paying they will. They like to see proof of why the surgery is needed. Best of luck.

[JetAirliner]

Finally received my implant a couple of weeks ago and went through a lot of the same issues that you are experiencing with my Insurance company ... In my case, we were able to confirm coverage one week before my procedure, but I was prepared to reschedule if needed

You will need a pre-authorization number to confirm coverage from your Insurance company ... It is important to get the contact information of not only someone from your Insurance company but also someone from HR in your company ... Once you have the pre-authorzation number confirming coverage (this is your ticket) you can either have the insurance company follow-up with your provider or have your provider follow up with the Insurance company to confirm coverage.

In my case I was denied three times (I was originally scheduled for earlier this year) .. I spoke with HR and basically said, WTF am I "suppossedly" paying for great insurance for "shitty" coverage ... I fought like a mother and my advice is do not accept no and make sure that you have someone "advocating" on your behalf.. In my case it both my HR Mgr. and my Insurance Broker ... Great investment.

[Floridaspeedo]

My insurance approval came through the night before surgery. The doctor did the original submission and I just kept following up with the insurance company.

Do not self-pay and expect to get reimbursed by the insurance company. Your insurance company has contracted rates which are much much lower than what an individual would pay.

I thought about doing that also and the doctor and hospital really suggests that I not go that route. Wait for the authorization to come through from the insurance company

[Gt1956]

Floridaspeedo, excellent advice. Getting money out of an insurance company is nearly impossible.
Unfortunately I'm going to be learning again. The hospital where I got my implant contracts out the anesthesiology to a group that does not bill insurance. Crap, I had to deal with this maybe 30 years ago for a surgery that my wife had. Not my favorite experience.

[Youngdeadpeener]

My insurance approval came through the night before surgery. The doctor did the original submission and I just kept following up with the insurance company.

Do not self-pay and expect to get reimbursed by the insurance company. Your insurance company has contracted rates which are much much lower than what an individual would pay.

I thought about doing that also and the doctor and hospital really suggests that I not go that route. Wait for the authorization to come through from the insurance company

So basically I should just reschedule? The final payment has to be given the day before surgery . I have a bad feeling that insurance won’t cover it due to my age , I’ve tried all the treatments for this but don’t have them on medical record except for cialis I was prescribed at 16, got them all through grey markets which I mentioned to the the doctor and he put it down that I’ve tried them and they didn’t work. I’m kind of at the point where it’s like I’m 70% sure insurance isn’t gonna cover so should I just pay out of pocket and get it over with or do I extend my wait time just to keep getting denied . Sounding very
Pessimistic I know but I’ve had this for so long that I don’t want to wait any longer

[wolfpacker]

If there was a chance insurance could cover your surgery with a surgeon as good as Clavell I would 100% try to use insurance.

The price of the surgery is already expensive enough (maybe $25k) but if you happen to have a complication like infection, you could easily triple that price

[iwantanewone]

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!