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Insurance Denying PART of Surgery
I'm wondering if anyone else has encountered this ridiculous denial and what, if anything, they were able to do to overcome it.
My doctor, one of the best robotic surgeons in the country, as part of his process does a special procedure on the urethra being tied to the bladder as to reduce incontinence and the need for any follow up sling or other solution after-the-fact.
My insurance says that since it's not demonstrated that I'm battling incontinence currently that this is not covered. I mean, they are already in there, how much extra time does this take?!?
I am waiting to hear from the doctor if they can do anything (since his notes are, apparently, what prompted this) and what the cost for that portion would be out of pocket.
Anyone else run into this type of BS?
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That's just ridiculous. I'm so sorry you have to deal with crap like that when you're already dealing with cancer.
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1 ReactionI am not up on these surgeries as I should be. I am curious what the procedure is called. My wife had incontinence issues years ago and when they did the hysterectomy they tied up the bladder or urethra. worked perfectly. Wondering if that might help.
The procedure pulls part of the bladder down to connect to the urethra in a way that prevents the “sagging” that can occur that is often leads to an incurable incontinence that has to be addressed with surgery, like a sling, to rectify.
In my head, and I am waiting to hear from the doctor on this, it’s an extra 15-20 minutes in surgery doing this procedure rather than whatever the norm is for connecting the bladder back up.
I remember asking him early in the process about incontinence and he went over the procedure and said the chance I would need a sling would be almost nothing and that this had been successful for him for many surgeries - which also leads me to think that he’s had to fight this battle with insurance before and won.
I have the means to pay for it out of pocket but don’t want to, it’s why I pay insurance companies every month!
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1 ReactionMy doctors determined I needed radiation treatment. My insurance company okayed the actual radiation treatment but not the doctor fees to set the radiation up. During one call to the insurance company I asked them if they would proceed with a treatment that a doctor hadn’t ordered. The customer service representative said yes they would. After my doctor sent paperwork, the appeal was successful. But the time and energy spent on this was awful.
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2 ReactionsI did not have this particular issue but Medicare would not allow me to be admitted overnight after my RARP. I was allowed to be kept ‘under observation’ but was moved to a small windowless room in an older section of the hospital. My doctor thought Medicare was ridiculous for their stance on this matter. I have Medicare A&B plus a regular plan G, not an Advantage plan.
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1 ReactionHey buddy, My surgeon, Dr David Samadi, has a similar description of this on his website. It’s a basic part if his SMART surgery protocol.
I paid him privately ($62K) and he did not fill out insurance forms - even as a means for patients to get reimbursed. He was in NO networks so there was no point.
All I can say is that so far I am not incontinent 🤞 even after salvage radiation. If he’s telling you to do this “extra” just pay the man and hopefully you’ll never know the misery of incontinence.
You can always try to get reimbursement later if you even want to pursue it. I insisted on a PET scan before surgery and got the same BS: “there’s no proof that this procedure, etc.,etc…” so I shelled out another$7500 for my own peace of mind.
Glad I had the $$ but it still sticks in my craw….
What's funny about your PET scan is that I asked my doctor, after my MRI showed bulging, if I should get a PET scan and he said "I doubt the insurance company will approve it but I agree it should be done", it was instantly approved. One has to imagine that a PET scan is more than some stitches to your bladder.
Oh yeah - and a lot more expensive too! But that was 6 years ago and a LOT has changed in that time…
Out of curiosity, how much is your surgeon billing the insurance company for these extra sutures? there must be an actual procedure code.
Remember, there’s the insurance fee and the real fee. Check to see how much he is charging (submitted fee) vs the “covered fee”. If he is IN network you should only pay the covered fee - THAT’s a FACT!
However, If he is OUT of network he is allowed to charge his submitted or private fee.
IMO, have the surgery done first, argue later!
Secret i was told stay less than 24 hours so not a full day. I was out in 23 hours. Needed to watch surgery time. Worked for me.
You see that going on in all areas of medicine. My wife recently had the cataracts removed.
Insurance wanted to "pay for one eye"! I am serious. Complete BS. They finally covered both,
but with heated arguments from the Dr.