Post by jennybenny025 on Apr 29, 2013 17:53:10 GMT -5
Any helpful tricks for getting insurances to cover for the surgeon you want?
I searched for bit to see if this was already discussed but couldn't find anything.
I'm from the Ann Arbor Michigan area. I have Blue Care Network (BCN). Originally in Jan. 2013 when I became extremely ill/painful, I decided to get the laparoscopy for long time suspected endo. My original OB offered to do the surgery herself via cauterization, and I was ready to do it right then & there, but she told me to take the weekend to do some research and think about it.
Well, I did exactly that, and through my research, I've found the wonderfully amazing Dr. Martin Robbins an endo excision specialist in Maine. I've learned more/more that an endo excision specialist is by far the way to go, with substantially less odds of needing repeated surgery again in the future. I researched endo excision specialists extensively and could not find any available in Michigan at the time. I spoke to a BCN customer service rep in great detail at that time, who looked up both Dr. Robbins the physician and all of his affiliated hospitals and they assured me that they were all covered in the "out-of-state" network. Assuring me that all I needed was a PCP referral and it would be covered in full.
Then the last business day before we were scheduled to leave town to travel to Maine, we found out that they would not authorize the surgery yet, as they want me to go to the Endo Clinic at the University of Michigan. And now my appointment with them is another month away. I seen a general OB at U of M (who had to refer me to the endo clinic), who said that they can excise large endo but usually ablate the smaller lesions. Reading online, they (U of M) have a 45% chance of the pain returning within the first year and increases every year after.
While Dr. Robbins reports 74% of his endo cases never need repeat surgery, and of those 26% that do get repeat surgery with him, its found that there is no residual endo by pathology in 61% of cases= 90% complete clearance of endo with 1st surgery.
U of M also support hormone suppression after surgery to help the pain free time last longer. However, with all my extensive research I've done, its my understanding that the hormone suppression is only needed if all of the endo was never excised to begin with, and these medications can have horrible side effects and often are worse off then without it.
Plus upon reading surgeon reviews Dr Robbins has many many rave reviews all of which score him with a 100% positive comments and always 5/5 stars in every category. Nothing short of amazing individualized comments from everyone. While only one the four endo surgeons at U of M have any feedback online at all (the others have none), and its only 75% with no additional comments (just the generic scoring).
So long story short, my question for you guys: is there any tips/advice, in convincing my insurance company to cover my surgery with Dr Robbins out of state? Dr Robbins already wrote BCN a letter explaining the importance of him doing this surgery with statistics and all. (prior to denial). It truly is better for me and them to allow me to see him, as it will prevent inevitable repeated surgeries later (if gone through U of M).
I can still file for an appeal of their decision. I am trying to find an OB/GYN who can confirm I need this surgery and it would be best if I had it out of state, however, I feel that everyone I see only sees Dr. Robbins as competition, and wants to do the surgery themselves.
Has anyone been through this? I have a good federal employee job, with great insurance (and pay a lot out of pocket each paycheck too).
Unfortunately, BCN is strongly affiliated with U of M Hospital, and I feel that they too would be getting more $ for themselves if I went to U of M (even if it was for repeated surgeries).
I feel that everyone except Dr Robbins, only sees me as a money paying repeated customer, as opposed to a very ill women who desperately wants to be cured (as much as possible).
Any advice to help get my insurance company to cover the cost for me to see the out of state endo excision specialists I want?
Thanks
Jenny
I searched for bit to see if this was already discussed but couldn't find anything.
I'm from the Ann Arbor Michigan area. I have Blue Care Network (BCN). Originally in Jan. 2013 when I became extremely ill/painful, I decided to get the laparoscopy for long time suspected endo. My original OB offered to do the surgery herself via cauterization, and I was ready to do it right then & there, but she told me to take the weekend to do some research and think about it.
Well, I did exactly that, and through my research, I've found the wonderfully amazing Dr. Martin Robbins an endo excision specialist in Maine. I've learned more/more that an endo excision specialist is by far the way to go, with substantially less odds of needing repeated surgery again in the future. I researched endo excision specialists extensively and could not find any available in Michigan at the time. I spoke to a BCN customer service rep in great detail at that time, who looked up both Dr. Robbins the physician and all of his affiliated hospitals and they assured me that they were all covered in the "out-of-state" network. Assuring me that all I needed was a PCP referral and it would be covered in full.
Then the last business day before we were scheduled to leave town to travel to Maine, we found out that they would not authorize the surgery yet, as they want me to go to the Endo Clinic at the University of Michigan. And now my appointment with them is another month away. I seen a general OB at U of M (who had to refer me to the endo clinic), who said that they can excise large endo but usually ablate the smaller lesions. Reading online, they (U of M) have a 45% chance of the pain returning within the first year and increases every year after.
While Dr. Robbins reports 74% of his endo cases never need repeat surgery, and of those 26% that do get repeat surgery with him, its found that there is no residual endo by pathology in 61% of cases= 90% complete clearance of endo with 1st surgery.
U of M also support hormone suppression after surgery to help the pain free time last longer. However, with all my extensive research I've done, its my understanding that the hormone suppression is only needed if all of the endo was never excised to begin with, and these medications can have horrible side effects and often are worse off then without it.
Plus upon reading surgeon reviews Dr Robbins has many many rave reviews all of which score him with a 100% positive comments and always 5/5 stars in every category. Nothing short of amazing individualized comments from everyone. While only one the four endo surgeons at U of M have any feedback online at all (the others have none), and its only 75% with no additional comments (just the generic scoring).
So long story short, my question for you guys: is there any tips/advice, in convincing my insurance company to cover my surgery with Dr Robbins out of state? Dr Robbins already wrote BCN a letter explaining the importance of him doing this surgery with statistics and all. (prior to denial). It truly is better for me and them to allow me to see him, as it will prevent inevitable repeated surgeries later (if gone through U of M).
I can still file for an appeal of their decision. I am trying to find an OB/GYN who can confirm I need this surgery and it would be best if I had it out of state, however, I feel that everyone I see only sees Dr. Robbins as competition, and wants to do the surgery themselves.
Has anyone been through this? I have a good federal employee job, with great insurance (and pay a lot out of pocket each paycheck too).
Unfortunately, BCN is strongly affiliated with U of M Hospital, and I feel that they too would be getting more $ for themselves if I went to U of M (even if it was for repeated surgeries).
I feel that everyone except Dr Robbins, only sees me as a money paying repeated customer, as opposed to a very ill women who desperately wants to be cured (as much as possible).
Any advice to help get my insurance company to cover the cost for me to see the out of state endo excision specialists I want?
Thanks
Jenny