Anyone know how to increase insurance reimbursements to dr

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JUJU8872
Regular Member


Date Joined Jun 2005
Total Posts : 349
   Posted 5/4/2009 11:52 AM (GMT -7)   
I have an "indemnity" Blue Cross Blue Shield policy. In other words, the policy pays 80% of "eligible" charges and I have to pay all the rest. I took this policy to use the PS I wanted and I expected to have to pay about one third of the charges. Seems like it is ore like half. I have asked for reviews. Been turned down. Trying voluntary appeal process now and have not yet received letters from my doctors to go along with my request for these @#$&s  to pay more money. It is actualy beginning to add up -- close to 5 figures.
 
Got any ideas?
 
Judy

Frayda
Regular Member


Date Joined Aug 2003
Total Posts : 248
   Posted 5/5/2009 11:12 AM (GMT -7)   
Unfortunately there is not much that you can do.  Your doctor can request a review, but he will have to document that the service he provided was more complex that the routine procedure that the benefit allowance was based. The benefit allowances are set by the insurance company themselves.  Your doctor has no obligation to accept what the insurance company considers "usual and customary", therefore you are responsible for the doctor's full fee.  It is very misleading to consumers when the large print on your insurance policy says they will pay 80% of the UCR.  You are then really responsible for everything that is not covered by the insurance which can amount to thousands of dollars in unexpected expenses. That is how an indemnity plan works; there is no panel of participating doctors that have agreed to accept the fee allowances. When a doctor signs a contract with a PPO or HMO the doctor has agreed to accept the insurance fees and the patient is responsible for only his/her co-pay. Hope this is helpful.

JUJU8872
Regular Member


Date Joined Jun 2005
Total Posts : 349
   Posted 5/6/2009 10:33 AM (GMT -7)   
Thanks for your reply. I went into this knowing all about this "indemnity issue". I just thought that I would be paying about one third rather than one half. My doctor has written me a letter to go along with my voluntary letter of appeal. It's a very informative letter iterating why I needed two rather than one operation (rads). We'll see, but I have already paid for the first operation. Now I'm worried about what I'll have to pay for the second. Oh, well, life goes on and with the possibility of National Health Care, I doubt I would ever qualify for reconstruction in the future.

Thanks for the reply, and I'll let you know how this goes.

Judy

Tavish
Veteran Member


Date Joined Jul 2003
Total Posts : 2272
   Posted 5/10/2009 1:49 PM (GMT -7)   
Judy, your doctor has some responsibility in this too....how much is he charging compared to the other local providers? As Frayda mentioned, those on a network panel with a carrier have to accept their fees which may be only about 60% of their charged amounts.

Some doctors charge rates that are double or 50% higher than the local "competitors." You may want to call around to other doctors and find out what they charge for procedures. You might also check to see if your plan has an out of pocket maximum, which would offer you some protection once the total has been reached.

As for the appeals, definitely appeal everything, it's your right. But be sure you have more information and documentation each time....eventually your appeals process becomes exhausted and if you get more info later, you won't be able to submit it for condsideration.
Good luck!


JUJU8872
Regular Member


Date Joined Jun 2005
Total Posts : 349
   Posted 5/17/2009 6:19 PM (GMT -7)   
Thanks, for the reply, Tavish. I have tried calling other doctors here, but no one will give me a price on this surgery, even with the code. As for the doctor, he has written me a letter giving reasons for his charges. Can you believe that I did not know that I could not lift my arm above my head? I guess I  had just adjusted to this part of my life. Anyway, I am in physical therapy now to help with this and am looking forward to doing the mastopexy sp???? shortly after June 15th. I do have an out of pocket maximum, but it is for "eligible charges" only. I am approaching this so the 20% will eventually go away. However, right now, I believe the devious insurance company is plotting to see how little they can pay on the rest of my claims so that I have to pay more.  HA! HA! HA! 
 
I appreciate everyone's advice and I hope all are doing well.  Will let you know how this turns out.
 
Judy
 
 
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