Tuesday, December 22, 2009

The Check's In Mail

...or so they told me many, many times. I haven't written about the insurance company experience until now. It was almost as painful as the surgery. Just in a different way.

It's taken seven months to resolve all the appeals with my insurance company. The net result is the insurance company did the right thing - they reimbursed the procedure based on the actual amount billed by the surgeon, as opposed to the “customary” amount typically set by medicare. The surgeon was not a preferred provider under my plan. In fact, there were NO preferred providers under my plan in my area who do MMA surgeries. When everything was finally settled, the insurance company agreed that they had no preferred providers in my area who do the procedure.

I had done as much as possible to work with the insurance company in advance of the surgery. The insurance company had approved the procedure as being medically necessary, but would not commit to the amount they would reimburse until the actual procedure was performed. They gave me the names of several surgeons in my area who they claimed performed the procedure– none of these physicians performed the MMA. Upon notifying the insurance company that they had no providers who perform the procedure, they said my only option was to have the procedure with a physician of my choice and take my chances on an appeal.

I went into the surgery expecting to get very little reimbursement from my insurance company. So it was no surprise when they sent me the first reimbursement and it was less than 10% of the surgery bill. My surgeon gave me some great advice - he said be very persistent and don't give up. He was right.

I wrote multiple appeal letters. The basis for the appeal was there were no preferred providers in my area that perform the procedure. Based on the insurance company's responses, it was clear that they did not read any of the letters I sent. Each response said I should have used a network provider and told me my only recourse was to appeal to my state’s insurance board. After receiving each denial, I wrote another appeal letter. The final denial included a list of preferred physicians they claimed preformed the MMA. I called each physician – each one referred me to the surgeon who actually performed the procedure. My final letter simply stated that their preferred providers referred me to the physician who performed the procedure. They agreed.

I woke up this morning and felt OK - coincidence? Perhaps.



2 comments:

  1. I am so happy for you. You give me hope as I also have BS and they paid very little. I had to take out a loan to have the surgery. If you would be willing to help me by giving me more details about how you did this, please email me! I'll buy you dinner! (If not, I totally understand) sararouse@sbcglobal.net

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