H.O. and insurance, need to make a tough decision

[Lazlo]

I finally got a CT scan of my heterotopic ossification problem in my left hip, and consulted a surgeon about it. This is the same surgeon that did my spinal fusion and femur fix. He says there's a lot of bone in there that needs to come out. (His exact quote as he panned across my CT results was "Wow that's a lot of bone... wow... wow...") but he feels he can get out enough to recover most of my range. I'm all set up to have the surgery on June 1.

However I got a call from their office saying that they are no longer in my insurance network, which means my insurance will only cover a portion of the surgery. I'm still waiting for a quote but from what I can tell it's going to cost me at least $3,000, probably more.

I'm well aware of the risks of the surgery, especially of recurrence of bone, and that it needs to be performed by a skilled surgeon. The HO has matured and hasn't gotten any worse in the last year. I have very little range left in the hip and I can't sit upright in my chair anymore.

So at this point I have the options:

- Pay for the surgery with the doc I have history with. Most expensive, but I get it done in a couple weeks and I'm close to home.

- Pick a local orthopedic surgeon "out of the hat" that's within my network. I live in Grand Rapids, MI. Somewhat less expensive but risky.

- Travel somewhere and have the surgery done by a skilled, in-network surgeon there. Cheaper than out of network but how do I find such a surgeon?

- Do nothing. Free, but I'm stuck in bed most of the time.

If anyone has surgeon recommendations I'm interested to hear them. This is a major surgery and I'm not looking forward to it at all, but to be able to sit up again would be fantastic.

[cheesecake]

If NY is in your network, I would consider Hospital for Special Surgery as all they do is orthopedic work. I know they have an experienced HO doctor.

[thehipcrip]

That sucks big time, Lazlo -- another case for why I'm for single-payer health care: everyone is in network.

I think there's another option worth exploring. Call your insurance company and ask to be assigned to a case manager, who will act as an in-house advocate on your behalf. Explain the special circumstances about why your ortho is uniquely qualified for doing this surgery, and have the case manager lobby to have your doctor treated as in-network for this procedure.

It's worked before when people can show that no one who is in-network has the familiarity with unique combination of patient conditions, etc. And it shouldn't drag out the process much longer at all -- my case managers were very prompt and proactive.

I think you have a decent shot at it. But if it doesn't work, step 2 for me would be lobbying the doc to accept the OON reimbursement as payment in full and writing off the balance. Doesn't help with the hospital charges, though, if the facility is now also OON.

If that also doesn't work and it won't cause you to lose your house/go to jail, go with your current surgeon and make a payment plan for covering the difference. His skill and your trust in him are well worth $3k.

I forgot you were in GR, my friend -- that's on my list of top two places we'll end up landing in MI when we can finally sell down here and get out of paradise. My best friend in the world and his family live over in that area ~waves to jonderson~.

[LindaT]

That's a tough one. The network system is so frustrating.
The case manager we have has been helpful with getting some equipment approved which are not always covered. At other times her ideas (I think she just looks in the phone book for docs in our area) are stupid. It would not hurt to try.
Would your doctor possibly be able to suggest another doc out of network?
Have you met with any docs in your network to see if you like them?
If you truly feel this is the best doc for you,the only one you trust and decide on the surgery you may want to go with self pay. THC suggestion sensible as always.
Good Luck!

[crypticgimp]

man that is tough. i'd go with ur current surgeon. i would speak directly to him about ur situation tho instead of going thru secretaries. gl and i rly hope u can get the surgery.

[Lazlo]

The number's finally back, $4,000 for the surgery.

Note to self, when insurance says they'll pay %70 of the bill, they mean 70% of the maximum they've decided to pay for the procedure, which is almost certainly less than what your doctor charges (about half in my case). After deductible of course. So in my case they're only covering about 30% of the cost.

[rdf]

Sorry for your problems Lazlo. I'd try someone in network, maybe look for a forum on the web that specializes in HO and go from there.

I didn't know you could get a quote for a surgical procedure.

[Lazlo]

I didn't know you could get a quote for a surgical procedure.

Neither did I, but the surgeon's office was very up front with the exact number, and the insurance company was right there with the exact amount they would cover. It's all based on a procedure code that the surgeon identifies from a big list of possible surgical procedures. That and the zip code where the surgery will take place. If you have that procedure code then apparently the numbers fall right out. Still, it feels strange getting quotes on bodily surgery as if you were getting your car fixed. I don't like it.

[rdf]

I've asked in the past, and always got the 'ole hemming and hawing, before getting no answer - masked in various excuses. I like the idea, it'd be nice to budget a surgery, to know the actual amount you'll be paying after insurance.

It's a hard hit to the wallet when you don't know what's coming in the mail, bill-wise, after a surgery.

Good luck to you Lazlo, hope you can get your surgery at minimal cost and by an experienced surgeon.Neither did I, but the surgeon's office was very up front with the exact number, and the insurance company was right there with the exact amount they would cover. It's all based on a procedure code that the surgeon identifies from a big list of possible surgical procedures. That and the zip code where the surgery will take place. If you have that procedure code then apparently the numbers fall right out. Still, it feels strange getting quotes on bodily surgery as if you were getting your car fixed. I don't like it.

[thehipcrip]

Lazlo, that number is your total OOP for the surgery only (OR use, surgeon fees, anesthesia and anesthesiologist costs, drugs during the operation, etc.) but not anything related to your hospitalization after the procedure, correct? I don't see how they could budget for the latter since there's no way for anyone to predict how your recovery will go.

It does feel strange to have a dollar value attached to work on your body, but I'm all in favor of it and for people being told up front exactly what they will be charged and what that covers.

Have you decided yet on what you're going to do re: pay for your current doc or seek someone in-network to keep your OOP costs down?

[Lazlo]

I'm trying to get a referral to a doc in network, and at the same time see if I can talk down the out of network doc. The facility is in network fortunately, though I might have to pay a separate $500 deductible for that stuff. I have to make a decision soon, or at least postpone the June 1 date.