"Out of network" insurance issues

[JenniferO]

I am in the pre-surgery mode of searching for the right surgeon for a hoped mitral valve repair in the very near future. I have a primary health insurance policy with United Healthcare of Utah in which I am for all practical purposes limited to one hospital and one surgeon of the caliber needed to attempt mitral valve repair. This particular surgeon can only give me a 50-75% chance of repair, so I am shopping outside of network for better odds. My diagnostic films have been sent to Cosgrove at Cleveland Clinic and to Dr. Lawrence Cohn at Brigham and Womens Hospital in Boston.

I am wondering if anyone has dealt with the out-of-network insurance problem. My policy provides for some out-of-network benefits at 70% of the UCR allowance, leaving me to pay 30% of the UCR up to an out-of-pocket maximum of $3,000. HOWEVER, the SCARY part to me is that the policy also states that in addition to my 30% copay, I am further financially responsible for the "gap" between the total charges and the UCR (i.e. those disallowed charges that are normally written off by the provider when you are IN-network). The financial counselor for Dr. Cosgrove at Cleveland Clinic has confirmed for me that my understanding is correct. I am a person of very average means and the thought of ending up with a $20,000 or more bill for the surgery is really keeping me up nights.

I have been able to pick up secondary health insurance coverage during the most recent "open enrollment" period with Blue Cross/Blue Shield as a dependent on my husband's insurance through his employment. I am also told by the CCF financial counselor that she cannot tell me if this will help or not.

Any one had experiences that might help me understand what to expect?

There are days of despair I think I should just forget trying to better my odds and stick with the in-network hospital, although that well may be the difference between a valve repair and a valve replacement.

Jennifer Olson

 

[Nancy]

Hi Jennifer-

I replied to one of your other posts as well. Just wondered if you have spoken with the surgeon near to you. The reason I'm asking is because there are many highly skilled heart surgeons outside of the large centers. Many of those have trained at the larger facilities and do hundreds of these surgeries a year and most belong to a larger regional group of cardiothoracic surgeons. In addition, in each area there are some hospitals which have made a concerted effort to provide their local residents the opportunity to have excellent care without the expense of travelling to distant locations. Being closer to home means that you are closer to your family and after care from your surgeon and cardiologist is a much better coordinated thing when they are nearby.

My husband had his first open heart in Boston in 1977, but has had the last two, plus his thoracotomies right here within 20 miles of home. We are blessed with an absolutely meticulous surgeon who is with a larger group of highly skilled cardiothoracic surgeons. The surgical care was the best and the hospital care was the best. The surgical team was the best.

So give local at least some thought, you might be surprised.

 

[JenniferO]

The problem with the "best" surgeons in my area is that they can only give me a 50-75% chance of repair. That doesn't feel like very good odds to me. Within the network, there is only one surgeon, the head of cardio-thoracic surgery at University of Utah Medical Center that I would even give a thought to operating on me.

(Just some background. I had Lasik surgery in May 1998 to correct nearsightedness. The surgeon who did it had done 4,000 surgeries before me and was supposedly one of the best in the West. He had a 3% complication rate so I thought my odds were pretty good. Unfortunately, I did have complications and have a virtually useless left eye as a result; bad double vision from irregular astigmatism caused by the laser which is NOT correctable by glasses or contacts.)

Jennifer

 

[Gail in Ca]

When I had my 1st AVR in '89 I chose a non contracting surgeon and cardiologist. It seemed like I was charged for many things. The anethesiologist fees( non contracted) and some others I don't remember.
Luckily the hospital was contracted with our health plan.
We had to take a 2nd out on the house to pay off the balance of the charges for that 20% that the insurance didn't pay. The insurance has reasonable and customary and of course what the Drs charge is more than the R & C. Then they pay 80% of that.
I chose a different surgeon the 2nd time,Dr Craig Miller, at Stanford, recommended the 1st time but on sabbatical then and he was contracted. What a difference!
My surgery cost me NOTHING!
Ask different cardiologists who they recommend as the most experience surgeon in your area , or who they would use if it was their loved one needing surgery. Then ask that surgeon how many procedures like that they have done. My 2nd surgeon has done over 1000 of my procedures, and I felt very secure knowing this.
Gail

 

[Jean]

Repair Odds

Repair Odds

JenniferO

I don't know hard figures, but from what others here have said repairs are often not possible and the surgeons can't tell until they get in the heart and see. You might check what other doctors would think on the odds.

Good luck and we will keep you in our prayers

 

[Gail in Ca]

I would agree that even if you expect a mitral repair, when the surgeon gets in there he may find that it isn't repairable. In my case, I was to have a mitral repair along with my 2nd avr.
However, when the surgeon got a good look at my mitral he said it was odd looking and not able to be repaired. Because I was at death's door going into my avr, he elected not to replace it either.
So, I still have a leaky mitral but take cozaar to keep my bp lower and hopefully won't need that mitral replaced for a long time, if ever.
Gail

 

[Nancy]

The opposite can be true also. When Joe was scheduled for his third valve surgery it was to replace the leaking mitral, but when the surgeon got in there, he was able to suture up the leak and so far all is well.

You just never know, and should not take too hard a line on anything related to valves. I think flexibility is always a good idea, because whatever the vehicle, the surgeon will do the best for your own given situation.

 

[Mara]

Jennifer
I hate insurance companies. They stink.
Fortunately, mine has paid everything to date, except for $250! Wow!
It is hard to know about out of network stuff. You have to be careful asking the insurance company too much because then it gives the reason to deny your claims!
Byt, if going out of network means you will hae the best docs. go for it, Nothing is more important than your health.

 

[ShanaleT]

Hey Jennifer! I am in the same boat you are. I am moving my surgery up to the 13th of Dec because my insurance is changing at the end of the year and the new company considered Atlanta "out of the network". Luckily, I thought to investigate this since my employer had not yet announced the changes. Good luck and I wish I could offer you some advise. Any hope your insurance plan could be changing in the future for the better?

Shana

 

[Lisa in Katy]

50 - 75% odds are pretty good, because like someone else said, they can't tell for sure until they get in there and see how much tissue there is to work with. My odds were lower than that because Rheumatic Fever had eaten away some tissue and left deposits on the rest, so I didn't even hope for a repair. I wasn't upset when I got a replacement.

As far as insurance companies go, going out of network is really not a good idea unless you don't have a good surgeon or hospital in network. It sounds like the one that you have talked to is probably good. If you go out, you will have lots out of pocket that you are responsible for that won't count toward your max out of pocket. 3 1/2 years ago, my hospital bill alone was $42,000. The insurance company might have considered $25,000 as R&C. There's also the cardiologist, surgeon, anesthesiologist, radiologist, pulmonologist, and I can't remember who else who filed claims.

United is a big company, even though they break it up into regions. This is generally just for manageability. They have contracted providers all over the nation. Are you sure you can't go somewhere else and be considered in network? I would call and ask to talk to the Director of Provider Networks just to make sure. As someone who worked in that industry for several years, I can tell you that the people on the other end of the phone don't always know what they are talking about.

 

[mimmidoe]

I would avoid out of network if there is ANY way. I somehow wound up with an out of net Pulmonologist this last go around, and am still getting bills for $800. for two days worth of visits. My question to them was, "who authorized THIS particular Doc". And, how DO they decide that?? The other Docs I saw from his SAME group, were on my list. So, should I pay this?? Im not thinking so. It is a hassle, and keeping up with the bills and explanation of benefits is a full time job, even when IN network.

On the other had, I would not, at any price, settle for less than the best. What a mamby pamby answer, huh? Good luck!

 

[Ross]

Boy do I know where your coming from!
I'm in the same circumstance and cannot afford to go out of Network, but the choices I have so far, are not good.
I'm in the process of trying to find a work around.
Too early in the game to be of help at this time, sorry.