Insurance

[IwillbeatPD]

Hey everyone,

Looking for some advice.

So I have had the hardest time with my medical ins company. Basically spent about 40 hours on the phone prior to surgery to make sure my implant surgery was covered, which they confirmed on a recorded line. Additionally, I was quite literally told "your safe guard is that we record our calls and we have a policy where we honor our word if we tell you wrong information on a recorded line".

Fast forward to after surgery, surgery not covered. I know, craziest thing. Needless to say, I've submitted an appeal stating exactly that my decision was based on their confirmation of coverage. Apparently there are 3 appeal layers, and the final layer involves my employer-which I'm thankful for. If it gets that far I think they can make the decision to tell them to cover it based on what happened.

All of that to say, I'm thinking long term and want to make sure I have coverage when I need a revision 5,10,15 years down the road. If my employees ins plan does NOT cover this (which I will absolutely verify at every employer), what are my best options? Of course I'm thinking I could not use my employees plan, which is disappointing because it's heavily discounted. But if I have to select an insurance company on my own, is there any recommended companies for those with an implant? Generally I'm very healthy so id probably want a high deductible plan for only serious medical issues, or surgeries (such as an implant surgery).

Any advice or help would be much appreciated.  

[Stepone]

Iwillbeat,

As you know if you read the other conversations on pricing. Insurance companies have various types of plans.
I have Medicare through Aetna and they covered all but about $800. Others have reported zero dollars out of pocket.
I would wait until you run into any issues. Since coverage changes year after year, it might be available or not available when you actually have an issue.
A word to the wise, when I got approved, I asked for an approval letter.
StepOne  

[Stabler]

May I ask what the reason for denial was? I'm asking because I have worked with insurance for years.

Stabler

[IwillbeatPD]

They said erectile dysfunction/sexual dysfunction was considered a plan exclusion, even though the policy bulletin they sent me clearly lists Peyronies, and says an implant is covered as long as I didn't smoke, do drugs,or have depression. And I had to have one of many conditions-Peyronies was listed as one. So, according to that, I met the criteria.

Additionally, as mentioned they told me on a recorded line it was covered in my plan multiple times even after being given the procedure, codes, hospital and doctor.

And lastly, the fact that when I asked for a letter stating that, I was told they have a policy at Aetna where calls are recorded to ensure they are upholding their word. So if they say it's covered they are obligated to cover it.

After surgery I was told by Aetna the policy bulletin Aetna sent to me didn't apply to me, and it's still excluded.

I was told the people who assured me it was covered were wrong.

I was told the policy mentioned that guaranteed coverage if they verbally tell me on a recorded line didn't exist.
 

[Stabler]

Okay so first, if the use of erectile dis function was listed as the primary diagnosis, it should not have been.The primary diagnosis, that should have been is Peyronie's disease, making it a medical need for the implant not cosmetic.

Next, there is never a guarantee in health insurance no matter what they say to you. Even if your procedure test etc.. need an approval and the doctor gets the approval there is still no guarantee of payment.

I believe you said you were appealing the denial, make sure that you get records from the surgeon showing a medical need for it due to Peyronie's. Your going to need to show that it was medically necessary and to be honest the surgeons office should be appealing this for you.

When the claim was submitted to your plan the surgeon did not provide enough clinical information to show it was medically necessary due to Peyronie's it sounds like the submitted based on erectile distinction based on what you have shared.

Stabler

[IwillbeatPD]

Thanks Stabler.

You are spot on actually. Initially it was billed as erectyle dysfunction, and the relationship manager at Aetna said once it was billed correctly it should resolve it. He later came back and said even if it was billed as Peyronies being the primary code, it wouldn't matter because it wasn't covered anyway.

Because it wouldn't be covered regardless I assumed they didn't care to hear more info about Peyronies from my doctor. Although they do have all of that paperwork anyway because my doctor sent it, which explains it's medically necessary.

A couple questions:

1. Do you think Aetna will end up covering it via the appeal process given that I went to such great lengths and they told me multiple times it was covered, which my decision to proceed with surgery was based on?

2. In a worst case scenario where they don't cover it, what do you think the chances are of my employer stepping in on the 3rd appeal to tell them to cover it due to the situation?

3. In an even worse case where neither 1 and 2 work, would I end up paying the normal out of pocket cost of this procedure? Which from what I hear on this forum, is around 20-25k? And if so, given the scenario, do you think they would write off a percentage of say 20,000?  

[Stabler]

So I strongly recommend that you appeal. It would be better if your doctor appeal because they HAVE all the medical records to send with the appeal itself. If the doctor won't do the appeal for you then yes absolutely do it and find out where records need to be sent and the. Call the doctors office and have them fax the records for you. If it is denied at a first level appeal with Aetna they should have a second and even a third level appeal. I would appeal at every level and be sure to include the conversations and any names and reference number you may have from the information provided by the plan to you when you were calling to see if this was covered.

I'm not sure how your employer would come into play here as they are likely providing the Aetna plan but if they offer services to help appeal this for you by all means use them.

Finally if it turns out that after all the appeals they still won't cover it, then you should ask if they offer a discount for cash payment and ask if they have financing available for you.

Stabler  

[Hawk]

As Stabler said, the physician should appeal this.  They not only have all the medical records, but they also have the expertise to argue the need and argue that this should not be classified as an elective or cosmetic procedure.  The doctor operated on you because they thought that your insurance would pay.  In part, you trusted their judgment. Finally, the physician stands to gain if insurance pays since most patients cannot pay this bill without insurance. They directly benefit from an insurance payment.  I have yet to hear of an implant being repossessed for non-payment.

[Stepone]

Hawk,
Thank you for giving some humor to a frustrating issue.
StepOne