Insurance Issues

[Christian]

I've read a few insurance posts on here and it got me worrying. The wife's having mitral valve surgery at the Cleveland Clinic in the next couple of months. We have a Blue Cross PPO that pays 100% for in network services without any referral requirement, and the Cleveland Clinic is in our network. Has anyone experienced a surgery with similar Blue Cross insurance? If so, how did it go? Any pitfalls that we can pre-emptively address?

 

[Mary]

Christian,
I had double BC/BS PPO coverage and I had no issues. However, my daughter is in upper management at BC, and she insisted that I call and talk to a service representative several months prior to surgery. They will quote you coverage amounts, and if they issue a quote, they have to honor it.

If they ask, or suggest, having a case manager assigned, I would stop and think before I agreed. A case manager is great for coordinating services, but they are working to keep the costs as low as possible for the company. If you understand your coverage, you can do it by yourself.

Don't forget there are policy deductibles that have to be met even at 100%.
In my situation, my deductibles had been met early in the year, and the valve replacement cost me nothing.

 

[geebee]

You should definitely call your customer service number and make sure all "pre" stuff is taken care of. There is always "fine print" in health policies and it is much better to do too much than to miss something.

Make sure you get names, dates and make lots of notes. Anything you can get in writing would be an added accomplishment. Be sure and ask for written confirmations.

Good luck.

 

[Christian]

Mary, what does "quote you coverage amounts" mean?

I'm not sure we have deductibles. All of her medical bills so far this year (including a $3,000 Cleveland Clinic bill for an echo and such) have been paid at 100%. But I'll look into it.

Our policy says that the hospital takes care of all of the pre-certification, and if they don't, then we're considered pre-certified by default. That sounds pretty good but who knows how it's applied.

Thanks to the both of you.

 

[jwusko]

Christian,

I had an AVR at Cleveland Clinic 8 weeks ago...I have a different carrier, but my advice like the others is to check w/ your customer service rep...CCF also has a "financial coordinator" you can talk to if you have questions...I had a deductible, and then an out-of-pocket amount. After I hit the out-of-pocket everything was covered 100% except co-pays...At this point it's all on the insurance companies tab, so anything that comes up is stress free...

Make sure you do you homework - you don't want to get blind sided with anything...

jwusko
AVR July 6th
CCF - Dr. Mee

 

[Mary]

Christian,
In my case, I had an "out of pocket" deductible of $500. That means during a calendar year, I had to pay $500 in medical expenses before the remaining 100% would kick in.

Sometimes there are "additional costs" that they don't pay and they won't count towards a deductible. For example, Betty warned me to not have my shoulder "iced" after my physical therapy treatments. The insurance company doesn't consider ice pack treatments necessary.So, I could have therapy covered at 100%, but still have an outstanding bill because therapy included a procedure that wasn't covered.

You can call Blue Cross and tell them that your wife is scheduled for VR in November. Give them the name of the facility (Cleveland Clinic), the surgeon, and any cardiologist you might be using while you're there. Blue Cross can then tell you positively if all three are "in network" and if treatment by them will be covered at 100%. If they tell you that, you're in the clear. You should document whom you talked to and the date and time of the call.

Since you are "in network" all providers have to check precertification. As you said, if they don't, they're out of luck. It's when you go "out of network" that precertification falls on your shoulders.
I hope this helps.
Mary

 

[catwoman]

Christian:

Sounds like you've already made sure the surgeon is in network.

Check out the anesthesiologist, too. An RN from my insurance carrier told me a couple of days pre-op that I might discover the anesthesiologist isn't in network.
I was in luck -- the anesthesiologist was in network.

 

[Christian]

I'm sure that Drs. Cosgrove and Stewart (the surgeon and cardiologist) are in network. I never thought to have Jill check about the anesthesiologist. Good idea. All good ideas, in fact. Thanks again everyone.

 

[Lynlw]

we have Blue cross PPO and never had to pay any thing for Justin's surgeries. we live in NJ and he had surgery in PA and Delaware, the hospitals said they would take care of everything, but I alwasy call bc just to make sure, Lyn www.caringbridge.org/nj/justinw

 

[Guest]

The advice you've been given is great! Run with it .

I, too, had Blue Cross/Blue Shield and had no problems. The only think I would add is to NOT let the hospital/clinic set up a "payment plan" with you prior to surgery. The hospital that did my 2003 surgery _insisted_ on setting up a payment plan before surgery. Only problem was that they did not submit their bill prior to other facilities/services, such as the anesthesiologist. So, the payment plan I had with the hospital was "null and void" because I didn't owe them as much as they thought I did (per BC/BS coverage rules, etc.).

HTH.


Cort, "Mr Road Trip" / soon2be ex-"Mr MC", 31swm/pig valve/pacer
MCfamily.models.HO.chdQB = http://www.chevyasylum.com/cort/
MC Guide = http://www.chevyasylum.com/mcspotter/main.html
"There's so much I need to say to you" ... Phil Collins ... 'Take A Look At Me Now / Against All Odds'

 

[Bill Hall]

Christian - Good luck to your wife and her surgery. I did have BC/BS and did go to the Cleveland Clinic. Unfortunately, I did have a problem with the surgeon fee (Cosgrove) which finally got resolved a year later. You should try to preempt this by going to the surgeon's billing office and asking about fees and when they will submit them. If I remember, they were slow to submit their bills and BC/BS seemed to think they were already paid. It caused me quite a bit of stress getting things straight, so worthwhile to check out ahead of time. Of course, you have already made the best choice with your wife to go to CCF. They have a fabulous reputation and great team for surgery.
Bill

 

[Jingbing]

It is important to check if the Dr. is in the net-work --- the list changes from time to time. The trouble of not using a in net-work is not only higher copay but also a great amount which is greater than BCBS allowed. You need to make sure the hosipital is in net-work as well. If all in net-work, we did not have problems with bc/bs. Quite nice. Jingbing