Insurance games

[Guest guest]

I've had approval for a while now from my insurance company but as

out of network. That means I would have a $5000 deductible and a 20%

co-pay on the hospital bill. We estimate the hospital bill to be

about $70,000 for the joint replacement so that would be a hefty

price for us to pay. In-network, I have a $2000 deductible and a 10%

co-pay so that is a huge difference. There are no in-network

surgeons in my area who do TMJ surgeries so I couldn't go to anyone

else if I wanted to anyway which I don't. Also my surgeon has done

my last three surgeries so why would I change now? There are very

few surgeons in the entire country who do TMJ joint replacement

surgery and mine does more than anyone else.

The insurance co-ordinator at my surgeon's office has been arguing

back and forth with my insurance provider to get in-network

approval. Today, they told her the only way they would pay in-

network would be if I see an in-network oral surgeon and get a

referral back to my surgeon. Fortunately she knows one of the in-

network surgeons and says it shouldn't be a problem getting the

referral from him. I tried calling them this afternoon but their

office was already closed. Now I have to try to set up an

appointment with the second oral surgeon sometime next week so I can

get the approval for my surgery in only 11 days. Ugh!

[Guest guest]

Hi ,

That is a great idea! I may use it myself. Our insurance had in

network provider clauses too, but they have NO orthognathic surgeons

in our state! There are some oral surgeons though. I am going to

call my surgeons office Monday and see if something like that could

be worked out. Great idea!

And take a look at your insurance to see if there is a cap on the

amount you are required to pay out of pocket with any one

procedure. I have the same thing in mine in that I have a 20% co

pay for an out of network provider. But there is a cap beyond which

I do not have to pay. That cap is $5000, which is called

my " deductable " . What that means is that I am actually liable for

only $1000 out of pocket expense with this (20% of $5000). Double

check this, because many policies have this kind of fail safe, so

that you are not saddled with huge bills for an expensive surgery.

I hope your policy is written like this too. I have double checked

with my surgeons office about this, and called my insurance as well,

and they both say that is how our policy works. It is worth

checking to relieve you of worrying about it as much. I am crossing

my fingers for you on this. Good luck!

Fran

> I've had approval for a while now from my insurance company but as

> out of network. That means I would have a $5000 deductible and a

20%

> co-pay on the hospital bill. We estimate the hospital bill to be

> about $70,000 for the joint replacement so that would be a hefty

> price for us to pay. In-network, I have a $2000 deductible and a

10%

> co-pay so that is a huge difference. There are no in-network

> surgeons in my area who do TMJ surgeries so I couldn't go to

anyone

> else if I wanted to anyway which I don't. Also my surgeon has done

> my last three surgeries so why would I change now? There are very

> few surgeons in the entire country who do TMJ joint replacement

> surgery and mine does more than anyone else.

>

> The insurance co-ordinator at my surgeon's office has been arguing

> back and forth with my insurance provider to get in-network

> approval. Today, they told her the only way they would pay in-

> network would be if I see an in-network oral surgeon and get a

> referral back to my surgeon. Fortunately she knows one of the in-

> network surgeons and says it shouldn't be a problem getting the

> referral from him. I tried calling them this afternoon but their

> office was already closed. Now I have to try to set up an

> appointment with the second oral surgeon sometime next week so I

can

> get the approval for my surgery in only 11 days. Ugh!

>