Help on Getting a Surgery Covered Out of Our Insurance Network

I have had to do this several times with my son. He has several problems.. What I have done is called the insurance co told them what the deal is, the only dr in network doesnt see kids full time and the other surgeon is out of network and your child needs the surgery. They might give u a bit of a run a round becuase it is not life threatening. If they deny your request you will have an opportunity to do an appeal. If an appeal is necessary this is what you will most likely have to do. idk if your daughter sees a physical/occupational therapist or not, if so, you will need to get a letter written by them as well as your pediatricain and the dr who will do the surgery stating why the surgery is necessary.
Good Luck
J.

I have not had to go through what you are with your daughter; nothing more than tonsils. Have you checked with the Shriners Hospital? I am not sure if they help with this type of illness but it is worth a shot. Last I heard they worry about getting the kids better and not so much about payment. I think they are pretty much funded by sponsers and the government. Not positive but it is worth a shot. I had a friend along time ago that had a son with Serable Palsy (spelled wrong) and she always told me that the doctors and nurses were so wonderful toward her and her son. Good Luck and God be with you!!

Unfortunately I have no help for you. I just wanted to wish you luck with your daughter's surgery, and say how happy I am you got a second opinion! We did the same thing with our son's ear tubes and felt so much more comfortable with the second doctor. I hope you find a way to stay with your desired surgeon. Good luck!!

There is a lot of good advice here working with the insurance company. As a former Human Resources Manager, I would also suggest working directly with your HR Manager/Benefits Manager and the insurance rep. who "sold" the policy to your company for coverage.

We delt with this when our daughter was born with a heart defect, i made several calls to the benenfit coodinator. I explained to them that there was no dr in network to handle my daughters care, this is where she had been referred and i wanted her to stay there. If the first dr is not really a pediatric specialist you should be able to get your plan to pay. You may have to get any xrays or lab tests at the preferred hopsital tho. That is what we do, although she does have to get echocardiograms and they let us do that at riley, due to the fact the i explained to them that she is a child and she needs pediatric specialists to read and handle all of her heart tests. Whoever you begin to deal with at the insurance make sure you write their names down and try to talk with the same person or the same couple people each time. We had to submit some paperwork and the dr did also but after a month or so i had the new specialist on our preferred list and she will remain there until our daughter is able to see an adult cardiologist. Good luck insurance can be difficult but it is doable.
H.

Hi L.,
Have you tried to call your insurance company to ask what you need to do? Just to clarify, the closed reduction procedure isn't actually "surgery" is it? It's my understanding that there's no cutting involved in a closed reduction; the "open reduction" is a surgical procedure. Good luck!

I've never had to negotiate for a child's surgery, but for my own and even seeing different docs, etc. You have to persevere. You have to figure out what angle will work with this company. the best point is:

"There is only ONE pediatric surgeon in your area and he doesn't even do it full time. You've found someone else in a nearby area who is EXPERIENCED in this procedure. You would like permission to have this other pediatric surgeon and hospital do the procedure and have it be treated as an "IN NETWORK" procedure since you cannot get this exact thing done in your area."

You probably already know this, but when you call and talk to them, make sure and take notes of your conversation. Write down the name of the person talking to you, and their phone number (in case your call gets transferred, etc., you want to know how to reach them again.) Make sure they are the one or their department is the right department for making this kind of determination. Ask what is required to have this approved to be "In Network" at St. Vincents. (They may need a request in writing, for instance. Or they may need your pediatrician to send a letter....He could say he recommends you go to st. Vincent's for their procedure has a higher success rate or something. --whatever the points are for having it done by that surgeon at St. Vincent's, he could mention this.) And don't worry- your doctor's office will do that. I am a transcriptionist and I type letters sometimes for doctor's offices...getting them to do it quickly is another matter...but they will do it.)

OK--If you've checked out all the requirements and dotted all the I's and crossed all the T's, and they STILL say no--it will be out of network- find out how much out of network pays. You can find out approximate surgeon costs and approximate hospital costs from the surgeon and from St. Vincents, but know that there are OTHER costs to surgery, like radiologist, anesthesiologist, lab work, etc. It could be they'll treat as out-of-network and it's 70% and in network would be 80% and it's not that much difference... and you and your husband decide to just go ahead and foot the bill for the difference. Or it could be a substantial amount, like out of network is 50% and in network is 90% or something like that. It's a decision you have to make. However, if you reach that point, you can also talk to St. Vincent's and ask if they have payment plans and explain the situation. They may even give you a discounted rate because your insurance won't consider them to be in network. Likewise the surgeon. You won't have as much luck with the anesthesiologist and radiologist in this regard, but possible.

On the other hand, you may be able to get the insurance company to consider it in-network and you'd get the same coverage as if you had it done at home.

Good luck! I hope it works out best for you and your daughter. I'd go where I'd feel more comfortable about her care...like you seem to feel with St. Vincent's.

My first pregnancy was complicated by toxemia and I required a high-risk OB for my second pregnancy. The insurance didn't want to pay the difference. (I had 22 prenatal visits) My OB was wonderful- said don't worry about the difference...if you can get them to pay- fine, but he didn't want us to have to pay it. They FINALLY paid the difference, when my daughter was 22 months old. Took some time, but perseverence does pay off, at least sometimes. :)

If there are no in-network providers for the kind of care you need, your insurer should cover the out-of-network provider. I'd suggest calling the insurance compnay first (number is on the back of your insurance card) and asking what to do to get in-network coverage in your situation.

Once, we were billed for some biopsies and our hospital happened to send them to a pathologist that was out of network for us, Well, we had no control over who our hospital sent the biopsies to, so I had to call the patholgist billing office, and the insurer, back and forth, until I finally got fed up and told them that I was going to file an appeal with the insurer. Like magic, the problem went away. Before the appeal letter even reached the insurer, somehow the patholigst and the insurer worked things out, and I didn't have to pay the bill.

If you need to go that route, you can always appeal the claim. There are usually instructions on the insurer's website on how to do this.

I work for a insurance company, you will need to go for the 1st consultation and ask the doctor to submit a pre-determination and to allow his services at in-network level. Also you need to check which hospital he does these surgeries at and see if they are in or out of network, just because the doctor gets approval does not mean any other doctor (ie:anesthiologist, etc..) is in network. Even if the approval is not given you can still have him do you would just pay the out of network fee's which are considerable.
Good Luck

All I had to do was call and talk to my insurance company. They covered a specialist for my son because there weren't any other pediatric specialists within a 50 mile radius. They issued a letter and it was fine.

This worked with my insurance company 10 years ago, whether it will work today I don't know but it is worth a shot.
I had a letter from our family physician and the child's doctor both stating the surgery was a necessity. I then got a letter from the specialist on their list stating he was not a pediatric specialist and couldn't see the child for several months and contacted the insurance company with all of the information and asked them to please recommend someone they would be willing to cover in this situation.
Naturally they do not want bad publicity so they came up with someone in 24 hours and we were on our way.

Call your insurance company and explain the situation to them. I know we have out of network coverage through our insurance. We have to pay a little more, but not a ton. The first step would be to call your company and speak to someone knowledgable. You may have to do a lot of paperwork, but they will probably try to work with you. If not, then talk to your doctor's office. They will most likely set up a payment plan for you. I know it's not ideal, but when it comes to our kids, there's nothing we won't do! ;) Good luck and prayers for you and your little one.

I will be honest I do not recommend this surgery for a child so young. My son had this surgery and it didn't take it was due to his bones being so soft and he was older then your daughter. I would seek serial casting first if you have not already done this. It is so worth it and can save your daughter so much pain ( yes this is a very painful surgery ) I hope the doctor you seen at St. vinecnts was dr. Kayes because he is the best and will help you seek other ways of treating this before doing surgery. I wish you the best of luck in what ever choice you make but because of this surgery my son now need his hip replaced so think twice before doing this without seeking all other treatments. Good luck

You can also check with the hospital billing department. Some hospitals will give you the in-network rate because it is not the child's fault that their institution is not in-network. The other fees associated, may have to be worked out with your insurance company and physicians. Take good notes and always get the first and last name of who you spoke with from the hospital and insurance company.