Any advice on making sure insurance will cover all? anesthesiologist, etc.?

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denverSurvivor
New Member


Date Joined Oct 2009
Total Posts : 7
   Posted 10/27/2009 6:02 PM (GMT -6)   
 
One person commented to me at work that they made a mistake with their dad's prostate surgery where the anesthesiologist was considered Out-of-Network, and they didn't know before the surgery.
 
Do you start these questions with the doctor, or the insurance company? Any advice to make sure we get it right?
Age: 52 yrs old
PSA: 5.1 in Sept, 2009, last PSA was 2.6 over a year ago
Biopsy: Gleason 6 (3+3) in 1 of 12 cores, the Right Lateral Apex. 4 PINs, 1 Atypical
Doctor does not see anything on ultrasound, nor feel any lumps, etc.


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 10/27/2009 6:29 PM (GMT -6)   
denver,

i can only speak from my own experience with what you are asking. all my doctors, hospitals, specialists, test centers cleared with my health insurance carrier on their own. i didnt have any problems or have any limitations with my choices. if you have the slightest doubt, then by all means, call and talk to your insurance company by phone, and be sure to get the exact name of the person(s) you are speaking with. good luck.

david in sc
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


MrGimpy
Veteran Member


Date Joined Jul 2009
Total Posts : 504
   Posted 10/27/2009 7:03 PM (GMT -6)   
In most cases if you pick an in-network hospital, all the services including dr's that the hospital provides are covered

You would never be able to get the names of every Dr that sees you in a hospital before hand to get them pre-approved

You can try to call the Hospital and ask them who the anesthesiologist will be for your upcoming surgery, but I doubt they will know
Stats:
Age: 52
PSA (2008)=1.9
Biopsy on Jan 09, 2009
One (1) out of twelve (12) cores was positive, plus external nodule found
Gleason Score = 3+3
Surgery (Da Vinci, robotic prostatectomy): 4/7/09
Removed Catheter: 04/19/09
100% bladder control - Pad free 7/09
PSA 7/09 undetectable, under .0


clrwtr
New Member


Date Joined Oct 2009
Total Posts : 2
   Posted 10/27/2009 7:34 PM (GMT -6)   
I was just warned about this very issue by my insurance company (BC & BS). They cautioned me to check to ensure that the anatheseologist was preferred otherwise they would not pay all of his fee. They also said that the DR and NOT his practice had to be preferred. I checked with the hospital and they gave me the name of the company with which they contract for these services and they confirmed that all their DRs were preferred under BC & BS. I can tell you from experience that even though a hospital may be participating under a specific policy that does not mean that all the labs and Drs they use are. It is a real hassle to determine but you are safer to take the time to check.

Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 10/28/2009 6:10 AM (GMT -6)   
Mr. Gimpy is correct about the hospital being in-network. I had a similar situation with a D&C I needed a few years ago. The hospital and my OB/GYN were in network but the anesthesiolgy group was not. I called my insurance company right away and told me not to worry - I was covered. As long as the procedure was done by an in network doctor and hospital, all services provided would be covered. To be safe, double check with your insurance company.

Good luck with your surgery ... we'll be waiting for you right here.
Husband diagnosed in 2/2008 at age 57 with stage T1c. Robotic surgery performed 3/2008. Stage upgraded to T3a (extraprostectic extension in posterior left). Perineural tumor infiltration present. Apex margin, bladder neck and SV negative. Gleason 3+4 (no change from biopsy). PSA results: April 2008 0.1; May 2008 0.0; August 2008 0.0; November 0.0; February 2009 0.0; May 2009 0.0; August 2009 0.1; September 2009 0.3. Met with radiation oncologist and began process for salvage radiation. CT scan and bone scan done on October 8. One spot on bone scan (clavicle) being investigated. Third PSA taken on October 16 - PSA IS UNDETECTABLE! Next PSA scheduled for early December. Urged not to begin radiation treatment until it's needed (no problem there!).


Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4829
   Posted 10/28/2009 6:15 AM (GMT -6)   
Out-of-Network DOCS are covered but at a much worse rate.  Depending on where you live and other factors - Out-of-Network is all there is so most insurance companys cut you a lot of slack. If you live in a big City like I do, you should be able to find an In Network...
Age 54   - 5'11"   205lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
06/25/08 - Da Vinci robotic laparoscopy
05/14/09  - 4th Quarter PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.


coxjajb
Regular Member


Date Joined Nov 2008
Total Posts : 184
   Posted 10/28/2009 5:43 PM (GMT -6)   
You should confirm that your doctor and the hospital are in-network with your plan. If you do that, the covered charges for all other providers, even if they are out of network, will be paid at the in-network rate. This is a common practice in the industry. Having said that, the claims shop may still screw this up because most claims are auto adjudicated i.e processed by a computer. If they pay at the out of network rate, they should correct the error when you bring it to their attention.
Age 51
Pre - Op PSA, 4.3
Gleason 3+4=7
Stage T1C
da Vinci Prostatectomy 8/1/08
No issues with incontinence since day 1 after catheter removal
Mild ED. Levitra works well for me
PSA 0.00 at one year post op


cave88
Regular Member


Date Joined Jul 2008
Total Posts : 76
   Posted 10/28/2009 6:02 PM (GMT -6)   
Denver Survivor,
What everyone has posted is good advice. Purg is right to get names, dates etc. When I had my surgery the DR and his staff was in the network but not the hospital. My surgery was done at another hospital. These folks apparently had been down this road before. The Dr came to the in network hospital with his nurses to perform the surgery. Everything was covered in network this way.

Jon
age:  46
1st psa Apr 08 3.06
2nd psa 6/16/8 4.02,  DRE showed nothing abnormal
biopsy 7/10/08 positive 5 of 12
Da Vinci 8/04/8 Parkview Memorial in FT Wayne IN 
gleason 3 + 3 = 6
prostate 27 g, 4 x 4 x 3.1 cm
Stage:  pT2cNXMX
margins:  apical margin involved
no extraprostatic extension of tumor
seminal vesicle involvement: absent
3 month psa  0.11, 11/08
6 month psa 0.12,  2/09/0
9 month psa 0.13, 5/01/09
1 year psa 0.20, 8/17/2009
started 39 radiation treatments on 9/22/09
 
 
 


engineer55
Regular Member


Date Joined May 2009
Total Posts : 121
   Posted 10/28/2009 6:24 PM (GMT -6)   
I had a non covered doctor but they were all over it, and very clear on the charges. I really think it is up to the hospital to work out the insurance stuff. If the used a out of program guy without your notice I would not pay the bill.
Dx'ed 5/08 one core 2%  out of 12  3+3 gleason
DREs all negative
PSA was in the 3-4 range then jumped to 7
I have the enlarged prostate, on the order of 100cc.  After taking Avodart for 3 months  my
PSA was cut in half.
I did Active S for a year but concluded that I didn't want a life
of biopsies and Uro meetings.
DaVinci on 6/24/09  UCI Med Center  Dr Ahlering, long surgery based on size and location
Final was 5% one side all clear, but had a huge 90 grm prostate
Now we work on pee control, ok at night but sitting is a big problem.


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 10/28/2009 8:10 PM (GMT -6)   
I was going to say what engineer said. They'll send you you nasty letters, threaten collection, etc., but in the end for the difference in network vs non network, they'll usually write it off.

What the heck, we are cancer survivors. No darn bill collector is going to intimidate us !
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.  Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)

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