Hi Desdemona,

The fact your insurance has an out-of-network benefit is a plus even if it is reduced to 50% payment. Is the 50% payment based on UCR? You may want to mention this to Dr. Scott and  pay only UCR balances not actual charges. Perhaps Dr. Scott  and the hospital will work with you on this.

You may have other options available to you such as asking the insurance company to consider a network contract with Dr. Scott so you will be in network rather than out-of-network.  You should have an appeal process through your insurance company. Usually the appeal needs to be in writing.  If your insurance is through an employer, and the insurance is self funded, you may want to also appeal to the employer. You might also ask the employer to get involved with the insurance company as it relates to your specific case.

Most insurance companies have "Centers of Excellence". You may want to ask your insurance company if they have them.  I would argue the fact this is still considered a rare disease and there are only a few moyamoya specialist in the U.S. I would think, given the rareity of moyamoya, that your insurance company would take this into consideration. You may want to speak to someone at the insurance company who has the authority to take your case to the next level. It is really better if you can put it in writing and send to the insurance company appeal dept.  If all else fails, and your son requires surgery, you may want to consider a "fund raiser".   

I don't know that an attorney can necessarily help. It depends on a number of factors. However, you can always call an attorney as some don't charge for a consultation. 

Often employer group insurance contracts stand in the way of flexibility depending on whether the employer is self-funded or fully-insured. If self-funded, the employer accepts all the risk and can therefore, call the shots. On the other hand, if fully- insured, the insurance company accepts all the risk and they call the shots.

I hope this helps. Please keep me posted on any progress with the insurance company and also to let me know how your son is doing.

Hugs,

Lore

I just want to add to the above posts that ALWAYS ALWAYS battle your insurance company if something doesn't sound right.  I had a recent issue with my company for some tests I had done at Columbia and it just didn't make sense.  It is truly a pain, and there's a part of me that wants to say who cares, I'll pay the extra money for the peace of mind, but to put it bluntly, I don't believe the health care industry deserves the profit.  When the codeine during my surgery costs the normal $.25 per pill insted of the $25 per pill they charged my insurance company, I won't make an issue.  Until then, phone calls will abound from me, for sure!

I'll get off my soapbox -- just want to remind you all not too be intimidated by the insurance companies!!

Trina

It's always worth the battle for good care. I had to battle Medicaid for Tyler. It was hard and scary, but Tyler was able to go to Stanford in the end.

Good Luck!