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Insurance Runaround
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Insurance Runaround

› Forums › Cutaneous Melanoma Community › Insurance Runaround

  • Post
    • November 15, 2010 at 5:35 am
    2atlascedars
    Participant

      I am scheduled for a SNB and WLE (with skin graft) on my acral lentiginous melanoma on my heel this coming Friday (diagnosed 10/26), and I am finding it difficult to ensure that I will be covered by my insurance for my upcoming procedures.

      I am scheduled for a SNB and WLE (with skin graft) on my acral lentiginous melanoma on my heel this coming Friday (diagnosed 10/26), and I am finding it difficult to ensure that I will be covered by my insurance for my upcoming procedures.

      Here are the details:
      I was referred to a cancer center by my dermatologist (who is in my insurance network…Aetna), but only 1 of the three doctors caring for me at the cancer center is in my insurance network. I called the insurance company and they told me to have my dermatologist file a referral and pre-certification for the other two doctors. I did this, but the dermatologist's office staff told me that they should only have to provide the referral (which they have already done). They said that they are not prescribing the surgery, so they shouldn't be involved with the pre-cert. I also spoke with the Managed Care Representative at my cancer center and she said that if one doctor at the center is in my insurance network, then they all are because they use the same take tax code.

      So…I have spoken with 3 different individuals involved in my care and they all said something different.  

      Does anyone know the best way to handle this so I don't wind up with massive un-covered medical bills following my treatment and procedures?

      Thanks,
      Mark from California

    Viewing 7 reply threads
    • Replies
        • November 15, 2010 at 6:27 am
        washoegal
        Participant

          Mark,

          I wish there was a way for no surprises.  My Onc was under plan as was Anesthesiologist, Hospital, thought I had it all covered.  OOPS  assistant surgeon not under plan, didn't even know there was going to be one.  The whole thing sucks, and there is not much you can do but make sure you are approved for surgery, the surgeon is under you plan and so is the anesthesiologist. 

          If you get a surprise like I did you can try appealing it, but I can tell you it didn't do me any good. 

           

          Good luck with you surgeries. 

          Mary,

          Stage 3

          • November 15, 2010 at 6:27 am
          washoegal
          Participant

            Mark,

            I wish there was a way for no surprises.  My Onc was under plan as was Anesthesiologist, Hospital, thought I had it all covered.  OOPS  assistant surgeon not under plan, didn't even know there was going to be one.  The whole thing sucks, and there is not much you can do but make sure you are approved for surgery, the surgeon is under you plan and so is the anesthesiologist. 

            If you get a surprise like I did you can try appealing it, but I can tell you it didn't do me any good. 

             

            Good luck with you surgeries. 

            Mary,

            Stage 3

            • November 15, 2010 at 2:53 pm
            lhaley
            Participant

              Call your State Insurance Commisioner and tell them the 3 answers you got. Let them help you get this mess straightened out before Friday!  They can act as a mediator.

              Also, can you make sure that you have the surgeon that is covered?  I would think the hospital would want to be paid and could help make sure each person working with you is in network. Why do they make this so difficult when your already stressed!!!

              Good luck,

              Linda

              • November 15, 2010 at 2:53 pm
              lhaley
              Participant

                Call your State Insurance Commisioner and tell them the 3 answers you got. Let them help you get this mess straightened out before Friday!  They can act as a mediator.

                Also, can you make sure that you have the surgeon that is covered?  I would think the hospital would want to be paid and could help make sure each person working with you is in network. Why do they make this so difficult when your already stressed!!!

                Good luck,

                Linda

                • November 16, 2010 at 8:50 am
                2atlascedars
                Participant

                  Thanks Mary & Linda,

                  I had another talk with a different person at Aetna today, and they confirmed that all three doctors are showing up in their system as being in the same Medical Group as the primary Onc surgeon (who is in their network), and that is how they will bill the insurance company (as the medical group), so I should be covered. This is consistent with what the Managed Care representative from my cancer center told me, so I think it sounds believeable. However, Aetna still requires that the cancer center pre-certify the procedure because it is an in-patient procedure (not an out-patient procedure).

                  As for contacting my state insurance commission, I will keep that in my hip pocket for now in case everything implodes at some point down the road.

                  I am still dealing with another issue though. I initially had a referral from my Primary Care Doctor to see a dermatologist (it literally said…"dermitology consult"). After the Derm did the biopsy he referred me to a cancer center for treatment. Before visiting the cancer center I went back to my Primary Care Doctor for another referral, and they told me they can't issue the referral, that it must come from the Derm, so I collected a referral from the Derm and met with the cancer center last week. In speaking with Aetna today, they told me that they will deny my claims without another referral from my Primary Care Doctor. I went back again today and pressed the issue with my Primary Care Doctor and I got another referral in time for my surgery this Friday (SNB & WLE with skin graft), but according to Aetna, I may not be covered for my consults with the cancer center doctor and Onc surgeon last week.

                  Any suggestions around this loophole would be appreciated.

                  Thanks again,
                  Mark from California

                    • November 18, 2010 at 1:46 pm
                    lhaley
                    Participant

                      Mark,

                      I've had to go through the appeal process a few times and have won each time.  It's a pain but it's doable. I think the insurance companies plan is that most people won't bother and will just pay.

                      I'm glad you got the surgery part worked out.  My favorite part when I call for information is how even when I'm preapproved they tell me that there is  no guarantee.  My insurance is Blue Cross from the State of Delaware (pension). I got a letter saying that all scans now had to be preapproved. My Dr. calls to do this and was told that's only if I was in Delaware. Since I live in SC now I can skip that step.  I still have them call each time, so afraid the rules will change mid-step!  I have a PPO plan so thankfully no Doctors need referrals.

                      Best of luck on Friday with the surgery!  You don't need this extra stress right now. Let us know how it goes.

                      Linda

                      • November 18, 2010 at 1:46 pm
                      lhaley
                      Participant

                        Mark,

                        I've had to go through the appeal process a few times and have won each time.  It's a pain but it's doable. I think the insurance companies plan is that most people won't bother and will just pay.

                        I'm glad you got the surgery part worked out.  My favorite part when I call for information is how even when I'm preapproved they tell me that there is  no guarantee.  My insurance is Blue Cross from the State of Delaware (pension). I got a letter saying that all scans now had to be preapproved. My Dr. calls to do this and was told that's only if I was in Delaware. Since I live in SC now I can skip that step.  I still have them call each time, so afraid the rules will change mid-step!  I have a PPO plan so thankfully no Doctors need referrals.

                        Best of luck on Friday with the surgery!  You don't need this extra stress right now. Let us know how it goes.

                        Linda

                      • November 16, 2010 at 8:50 am
                      2atlascedars
                      Participant

                        Thanks Mary & Linda,

                        I had another talk with a different person at Aetna today, and they confirmed that all three doctors are showing up in their system as being in the same Medical Group as the primary Onc surgeon (who is in their network), and that is how they will bill the insurance company (as the medical group), so I should be covered. This is consistent with what the Managed Care representative from my cancer center told me, so I think it sounds believeable. However, Aetna still requires that the cancer center pre-certify the procedure because it is an in-patient procedure (not an out-patient procedure).

                        As for contacting my state insurance commission, I will keep that in my hip pocket for now in case everything implodes at some point down the road.

                        I am still dealing with another issue though. I initially had a referral from my Primary Care Doctor to see a dermatologist (it literally said…"dermitology consult"). After the Derm did the biopsy he referred me to a cancer center for treatment. Before visiting the cancer center I went back to my Primary Care Doctor for another referral, and they told me they can't issue the referral, that it must come from the Derm, so I collected a referral from the Derm and met with the cancer center last week. In speaking with Aetna today, they told me that they will deny my claims without another referral from my Primary Care Doctor. I went back again today and pressed the issue with my Primary Care Doctor and I got another referral in time for my surgery this Friday (SNB & WLE with skin graft), but according to Aetna, I may not be covered for my consults with the cancer center doctor and Onc surgeon last week.

                        Any suggestions around this loophole would be appreciated.

                        Thanks again,
                        Mark from California

                        • November 18, 2010 at 11:18 am
                        Suzan AB
                        Participant

                          Hi Mark,

                          I have had such a difficult time with my insurance company Blue Cross.  I would suggest writing a letter to Aetna describing the conversations with their claims people.  From what I gleaned from your posts, the claim rep. never told you that you needed two referrals.  My Goodness…Remind them that there is an appeal process and that you will pursue it as an option.  (I went all the way to the State Insurance Board and won the use of GM-CSF for off label use.)

                          Get your membership book out and read it.  I would suggest everyone take a moment or two and read through their insurance membership book to see what is really covered and what is required for procedures.   If the insurance company says no, then there is an appeal process.  1) Insurance company turns you down.  2) You write an appeal letter to your insurance company explaining why the doctor is right and they are wrong.  You doctor must also send a letter of his own explaining why his chosen RX or procedure is the correct one for you at this time. 3) Insurance denies your claim again. 4) Request an appeal from the State of Cali Insurance Commission (if it is a life/health insurance plan) or write to Managed Health (I think that is the name, they cover PPO's and HMO"s)  You can call the State to find out which department is the right one.  5) Explain why this is the option for you.  Make sure to include studies, reports to support your case.  

                          Good luck Mark!  Life is having melanoma, stress is dealing with the insurance companies. 

                          My best to you and yours,

                          Suzan AB

                          Stage IV

                          • November 18, 2010 at 11:18 am
                          Suzan AB
                          Participant

                            Hi Mark,

                            I have had such a difficult time with my insurance company Blue Cross.  I would suggest writing a letter to Aetna describing the conversations with their claims people.  From what I gleaned from your posts, the claim rep. never told you that you needed two referrals.  My Goodness…Remind them that there is an appeal process and that you will pursue it as an option.  (I went all the way to the State Insurance Board and won the use of GM-CSF for off label use.)

                            Get your membership book out and read it.  I would suggest everyone take a moment or two and read through their insurance membership book to see what is really covered and what is required for procedures.   If the insurance company says no, then there is an appeal process.  1) Insurance company turns you down.  2) You write an appeal letter to your insurance company explaining why the doctor is right and they are wrong.  You doctor must also send a letter of his own explaining why his chosen RX or procedure is the correct one for you at this time. 3) Insurance denies your claim again. 4) Request an appeal from the State of Cali Insurance Commission (if it is a life/health insurance plan) or write to Managed Health (I think that is the name, they cover PPO's and HMO"s)  You can call the State to find out which department is the right one.  5) Explain why this is the option for you.  Make sure to include studies, reports to support your case.  

                            Good luck Mark!  Life is having melanoma, stress is dealing with the insurance companies. 

                            My best to you and yours,

                            Suzan AB

                            Stage IV

                        Viewing 7 reply threads

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