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Insurance questions for surgeries (Read 7949 times)
Reagan
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Lee's summit, USA, usa, 302, 159, MO, Missouri
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Insurance questions for surgeries
Jan 12th, 2008 at 12:31am
 
Okay,

I live in Missouri. My insurance will only cover in-network in Kansas City and parts of Kansas. Dr. Steinburg is who we are being directed to see. I do have out of network but I don't have an extra 3500.00 to cover the out of network. Any ideas on how to get them to cover in network for a MM specialist? They told me to try KU Med Center. I was reluctant when I called and they had no clue what I was talking about in the neurosurgery department.

Reagan
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KTiller
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Freeland, USA, usa, 51, 28, WA, Washington
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Re: Insurance questions for surgeries
Reply #1 - Jan 12th, 2008 at 4:19pm
 
Because Stanford Medical Center is a teaching hospital, they offer financial aid to those who can't afford their medical care. Take a look at the hospital website, here's the link http://www.stanfordhospital.com/forPatients/financial/financialHardship
Also call Dr. Steinberg's office directly - they may be able to help. Ask your insurance company if they will pay a larger percentage of the cost as your physicians are refering you to an out-of-state specialist because the expertise isn't available in your area. I wouldn't want to have the suregery done by a surgeon who hasn't had a great deal of experience with moyamoya. I could have had surgery with a competent surgeron here in Seattle, but chose Dr. Steinberg because he is a moyamoya specialist and had done twice the number of STA-MCA surgeries - over 500.
By the way, I grew up in Gladstone, Missouri. Sure don't miss the snow and cold weather this time of the year. Instead it's wet and cold here in Seattle, but you can't shovel water  Wink.
Best of luck, Reagan
Kim
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STrantas
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Philadelphia, USA, usa, 490, 122, PA, Pennsylvania
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Re: Insurance questions for surgeries
Reply #2 - Jan 21st, 2008 at 9:15am
 
Also - just to let you know what I experienced.  This was with Children's Hospital in Boston, but I believe most hospitals will work with you.  I ended up paying about $2000+ out of my pocket (I was out of state, deductibles, etc.).  The hospital setup a payment plan for me.  They would allow me to pay $5.00 a month if I needed to.  I ended up paying more than that - and when I could, I sent extra money.  The bottom line is that they want their money - but hospitals are usually willing to work with you to get it!  Just my experience....

-Shari
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Lore
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Delaware, USA, usa, 419, 133, OH, Ohio
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Re: Insurance questions for surgeries
Reply #3 - Jan 21st, 2008 at 11:35am
 
Hi Reagan,

Does the $3,500 out-of-network include both the hospital and the doctor charges?

Out-of-network charges can get very expensive and especially when it includes both hospital and doctor charges.  I would verify your actual total out-of-pocket expenses for both the hospital and the doctors charges.  It depends on how your insurance policy reads as to whether or not there is a maximum out-of-network out-of-pocket expense..  I simply caution you about this as I have seen folks get burned with a lot of out-of-pocket expense due to being out-of network.

What type of insurance do you have? HMO or PPO?

What is the name of your insurance company?

Sometimes, insurance companies will negotiate out-of-network services as in-network through a contract with a particular hospital and doctor (s) when it involves a rare disease and the treatment options are few and there is a lack of knowledge about the disease such as with moyamoya.

It doesn't sound as if your insurance company has any in-netwrok contracts outside of Missouri however, some insurance companies have what they refer to as "centers of excelllence" for specific diseases and the treatment of those diseases such as cancers and transplants and negotiate in-network services. They may be willing to do this for moyamoya.

Doubtful, but your insurance company may have a contract in place with Stanford for something other than moyamoya but may be willing to negotiate a contract for services with Stanford moyamoya center and doctors as in-network.  You may want to mention to your insurance company that Stanford is the only moyamoya certified center in the USA.  The fact the hospital your insurance company suggested you contact didn't know what moyamoya is lends credit to getting to a moyamoya specialist and your insurance company negotiating an in-network benefit for you with Stanford and Dr. Steinberg.

Since moyamoya is considered rare and there are only two moyamoya specialist in the USA, I would contact your insurance company to see if they will consider negotiating an in-netwrok contract with Stanford and Dr. Steinberg.

Also, some insurance companies have nationwide networks in place.  They may own the network or they may lease the network but I would  ask them about their network affiliations.  It could mean the difference between in-network and out-of network charges and may be easier for them to negotiate an in-network benefit if they already have contracts in place even though it may be an out-of-network arrangement.

If your insurance company won't negotiate an in-network benefit payment, Kim and Shari have given you other helpful and valuable optins to consider.

I hope this helps and please keep us posted.

Hugs,

Lore



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"What lies behind us and what lies before us are tiny matters compared to what lies within us." - Ralph Waldo Emerson
 
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Reagan
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Re: Insurance questions for surgeries
Reply #4 - Jan 21st, 2008 at 2:35pm
 
thank you guys for your responses. I am traveling to Stanford next month to have bypass on my left side. I am in contact with my insurance company. They are working with the supervisor to contract in network pricing. My in-network out of pocket max is 1500.00. I have already met 1000.00 of that. I am praying they will consider this. They will probably need the dictation letter from Dr. Steinburg but they know it is a rare disease and there is nobody who is a specialist who treats it in Missouri.

I have a PPO with Marcit. I don't know how to explain it. My husband is a union firefighter/paramedic and the union consists of several departments that contract their insurance rates through Marcit. I am reviewing the out of network as we speek. My total out of network cost would be 4000.00 max whether it is the Dr. or the hospital. I will await to hear back from the supervisors from my insurance. Thank you once again.

Sincerely,

Reagan
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Cherry (LuckyMe)
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Chicago, USA, IL, Illinois
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Re: Insurance questions for surgeries
Reply #5 - Apr 11th, 2008 at 11:04pm
 
Lore,

I'm insurance with Blue Cross& Blue shield Illinois HMO.  If I chose to go Standford, do you know how much the total cost could be?(Hospital & doctor)  I don't remember the limitation of out of network on my policy since I never used any before.  Hopefully it's not gonna cost me an arm or leg.

does anyone have experience using Blue cross HMO in Standford?

Thanks.
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lflores
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Re: Insurance questions for surgeries
Reply #6 - Jul 31st, 2008 at 8:34am
 
HI,
My on was just diagnosed July 28th.  We also have Blue Cross Blue Shield IL and wondering the same thing.  I want to go to a doctor with the most experience.  My son also has mixed cerebral palsy (meaning he has different types of cerebral palsy) - That is another reason I want the best of the best!
Linda
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Shan
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Posts: 849
Honolulu, USA, usa, 376, 346, HI, Hawaii
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Re: Insurance questions for surgeries
Reply #7 - Jul 31st, 2008 at 2:16pm
 
Hi Linda,

I have HMSA (Blue Cross Blue Shield) as well and had no problems in receiving coverage out of state when I traveled to North Carolina for my surgery.  Did you mention that you have "HMO?"  That may make a difference, as I have "PPO."  I know of another MM patient here in Hawaii who also faced a lot of red tape with her insurance (Kaiser) and ended up changing her medical insurance so she could receive the care she needed.  I'm not suggesting going this extreme but know that you are not the only one trying to figure out the whole insurance ordeal.

If you or your PCP is able to write a letter to your insurance company explaining that the medical care you need is not avalable in your surrounding area, I believe they should cover you.  Are you able to contact your insurance company and just flat out ask what do you need to do to obtain coverage out of state?   Smiley

Nonethelss, as mentioned above, I'm sure all hospitals are willing to work out a payment plan with you.  My concern is that you don't let the insurance hold you back too long from seeking the proper medical care your son needs.

Take care,
Shan

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Lore
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My brother Kevin (Cubbie)
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Posts: 819
Delaware, USA, usa, 419, 133, OH, Ohio
Gender: female
Re: Insurance questions for surgeries
Reply #8 - Jul 31st, 2008 at 7:58pm
 
Hi Linda,

It does depend on the type of insurance plan you have as to how easy or how difficult it is if you want to go out-of-network.

If you have a HMO it may be more difficult depending on the HMO if it is a closed provider network like Kaiser. Blue Cross and Blue Shield have nationwide networks in place but they may say those particular networks don't  apply to your particular plan.  However, most insurance companies have "centers of excellence" for things such as rare cancers.  The fact Moyamoya is still considered rare and there are only a couple of MM Specialist in the USA that have performed hundreds of revascularizations on MM patients such as Dr. Steinberg at Stanford, you can appeal to your insurance company if they deny your request to be treated out-of-network.

When my brother got denied to go to Stanford, I argued with the insurance company and when that seemed to go nowhere I got my congressman involved by simply contacting him and his staff got on the case immediately.  After that, my brother was on his way to Stanford and that was the end of that.

Let me know what type of plan you have with BCBS whether it is a HMO and if the HMO is a "closed" network meaning you can't go out-of-network or if you have a PPO.  If you have a PPO, it will be less difficult but you may have to pay out-of-network costs so I caution you as that can be expensive.  What you will want to do if you have a PPO is to get your insurance company to negotiate a contract with the hospital and doctor you want to treat you if that hospital and doctor is not a "netwrok" provider.

I will assist you further once I know what type of plan you have.

Hugs,

Lore
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"What lies behind us and what lies before us are tiny matters compared to what lies within us." - Ralph Waldo Emerson
 
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KTiller
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Freeland, USA, usa, 51, 28, WA, Washington
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Re: Insurance questions for surgeries
Reply #9 - Aug 1st, 2008 at 3:52pm
 
IHi Linda,
have Regence Blue Cross Blue Shield in Washington State. I had my surgeries in Stanford, Calidornia last year. Once I met my $1,500 yearly deductible my insurance paid at 80% (that was easily met with all the earlier diagnostic testing done here in Seattle) then when I met the $2,500 max for out of pocket expenses they paid 100%.
If you talk to Bob in Dr. Steinberg's office, he will talk to your insurance company and make the arrangements with them. He knows the insurance lingo, just how to state the case for having moyamoya surgery with a specialist, and is able to negotiate terms with major insurance companies, including the HMOs. I've never had to speak with my insurance company; Dr. Steinberg's office took care of it for me. I'd recommend that you accept their help as you've enough on your plate making arrangemenst for your stay in Stanford without the added stress of dealling with the insurance company.
I'd also ask Bob about the total amount of the typical bill for the surgery - he'll have that information. Depending upon your income he may be able to arrange for you to stay in Stanford Housing at a very reduced cost.
Hope this helps and best of luck to you and your son.
Kim
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Re: Insurance questions for surgeries
Reply #10 - Aug 2nd, 2008 at 7:34pm
 
Thanks so much for your reply and info.   It is just so scary.  It seems like it just has been one thing after another with my son.  Everyone says my son is so atypical.  WE have had him checked for so many different things.   Maybe this will be the answer to our prayers.   Thanks again.

Linda
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lflores
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Re: Insurance questions for surgeries
Reply #11 - Aug 2nd, 2008 at 7:39pm
 
Kim,
I have blue cross blue shield hmo.  We have been approved in network to see a dr. Yamini at University of Chicago.  I tried to email dr stienberg but have not heard back yet.  We will go to see Dr Yamini, but will not stop there.  It would begreat if Dr. Steinberg would help us with the insurance glitch.  The travelling is not a problem as my husband works for an airline.  You guys are so great.  Thanks for all the help.

ps  Has anyone known anyone that has mm as well as cerebral palsy?

Linda
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Audge
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Daughter Emily has MM

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Armada, USA, usa, MI, Michigan
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Re: Insurance questions for surgeries
Reply #12 - Aug 2nd, 2008 at 10:31pm
 
Hi Linda,

You should call Dr. Steinberg's office and speak to Bob about any insurance questions.  They may have you send medical information first to see how things look.  It went pretty quickly after that and everyone is helpful.  Have you been to the Stanford website?

Also, you should start a new thread to ask if anyone else w/MM has cerebral palsy.  You will probably get a quicker and larger response.

Welcome to the website! 
Audrey
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KTiller
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Freeland, USA, usa, 51, 28, WA, Washington
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Re: Insurance questions for surgeries
Reply #13 - Aug 3rd, 2008 at 3:09pm
 
Hi Linda,
The telephone number for Dr. Steinberg's office is:
650-723-5575
The fax is:
650-723-2815
You might want to give them a phone call to follow up on your email. His team meets every Monday afternoon to review all of the films that have been received the previous week. Usually they get back to everyone either that very evening or the following day. If you haven't already done so, you can email your son's diagnostic scans to the office or send the CDs directly to Stanford. The address is:
Stanford University Medical Center
300 Pasteur Drive
Room R281
Stanford, CA 94305-5327
I'm sure you'll soon find the right plan for your son.
Best wishes,
Kim
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