Please help me decide what to do

[aaamom]

As some of you know, I was scheduled to have a tummy tuck next Tuesday, October 24th. I was all set as far as taking the time off of work, having someone cover for me for the 2+ weeks, having my DD take the time off, someone is covering his shifts, having childcare arranged for the day of surgery, etc etc. Well, I just got word yesterday that my insurance FINALLY decided they will not pay. Well, I did decide to appeal immediately mostly because my PCP really feels like it should be covered due to the fact how bad my pannus is. So I need help......
Do I cancel the surgery until I hear back from my insurance regarding my appeal? This could take up to 30 days....
Do I go ahead with the surgery on the 24th and cross my fingers that I will get reimbursed?
My DD says that no matter what, I will get this done. It would be nice to have it covered, though. Or at least know that it won't be so I can get on with my life.
And, if I decide not to do it now, then I think I will have to wait until after the first of the year due to the holidays,etc.

Any and all comments/suggestions would be greartly appreciated.
THANKS
Leah

[DonnaB]

Hi Leah,

If it were me, I would probably cancel the surgery and appeal. Your PCP thinks the surgery is medically necessary so it will probably be covered, but it's all too easy for your insurance to deny coverage on some technicality once it's already been done. You need to be able to jump through every hoop they put in front of you and that's pretty hard to do after-the-fact.

It seems like a big pain in the butt to rearrange everything, but it will be worth it in the long run if you don't get stuck footing the bill.

The hardest part is overcoming the feelings of frustration - you're all ready, you've made all the arrangements, you're in the frame of mind where you just want to throw up your hands and move forward. Insurance companies DREAM of these kinds of situations. They get out of paying for covered surgeries - stuff you're already paying for in your insurance premium. If you end up paying for it out of pocket now, you'll effectively be paying for your surgery twice.

Having said that, and knowing myself pretty well (!) I know I would have a hard time cancelling and rearranging everything! Sorry, I'm not much help for you!

Best wishes on your difficult decision. Let us know what you decide to do.

[aaamom]

Thanks Donna for your input !! I need all the advice I can get. I am in tears here not knowing what to do!!!

[Telly]

Being in the medical field, I have fought many battles with insurance appeals and 70% of my appeals are overturned and paid. The appeals are of course post surgery or post procedure that was performed.

If it were me, I'd go ahead and keep the date. The insurances do take awhile to respond, but they also sometimes respond within a week of an appeal and if you are on the phone daily, they will tell you where the appeal is, whose reviewing it and what the decision is. I would call daily. Also too, if your tummy tuck is scheduled and done and you are still in appeals with the insurance, even though your doc sent a LMN to the ins company, you should not be required to pay for the tummy tuck until the final hearing and final appeals are done. After which, (even though you were getting it done, either way), you will either have it covered, or you will pay for it and maybe you can work out payment plans with the provider performing the procedure, maybe even ask for a cash-self pay discount. Trust me when I tell you that 100% of the time patients call me and ask for a discount, I have a preapproved (30%) discount in which I can give them on all bills, but they would have to make some form of payment over the phone, 25% - 100% for the discount.

[aaamom]

So Telly, do you think if I went ahead with the surgery date of Oct 24th, and paid out of pocket (the docs office wants 100 % which equals $6803), and the appeal gets overturned, I get reimbursed???

[Telly]

Yes you would get reimbursed only if your appeal is overturned.

If so, then you would ensure that your provider is fully aware that if they are in-network with this insurance company, then they would have to accept the insurances allowed amount and not balance bill you for the difference.

Therefore..say.. The surgeon charges a flat fee of 7,000 for every single patient, insured or uninsured and they are in-network with your insurance. Your insurance allows only say.. $5,500 to be billed and they paid 80% of that..etc. The doctor should only make you liable for the allowed amount b/c they are in-network and according to their contract, they should not charge you over the contracted allowable rate. So.....to recap

1. Yes, if the appeal is overturned then they will reimburse you, however make sure your doctor is aware that the check should be mailed to you directly and in your name, not the doctors name. To do this, the doctors office needs to send out your insurance claim with a "NO" checked under "Accept Assignment?". Not accepting assignment will allow any payments made by your insurance company to go directly to your mailbox.

If your appeal is overturned and is payable and mailed to the doctor anyway, (as this sometimes happens) ensure that the doctor either hands over the check to you or cashes it and writes a different check out to you. Sometimes doctors forget to properly reimburse patients and if you don't ask, sometimes they don't see it and forget to refund the patients. *Smirks*

2. If he is in-network then ensure he charges you at the in-network rate, based on what your insurance company will allow or is allowable. Do not allow them to balance bill you if they are in-network. If they are out-of-network then you owe it all. If you are out of network and your insurance pays any of it at all, your surgeon will still owe you whatever the ins paid b/c you'd be paying up front.

I hope for your sake the appeal is overturned and you're covered or even partially. If you have any questions, you can send me a PM and I'll help however I can.

You should get a copy of the LMN from your doctor. (Letter of Medical Necessity) and find out when the LMN was sent, copy of your appeal and any other documentation you may need to fight this. If you have pictures of your panni and any skin irritations, complaints of odor, pain, etc., ensure he documents all of this. It may help you.

I hope Newsho doesn't mind I copied her link but this is one of her pages. It may help you.

http://www.newsho.zoomshare.com/2.html and her own help website

http://www.getinsuranceapproval.com/

[Telly]

Aaamon, did you ever find anything out?

[aaamom]

Hi telly, Thanks for asking. I am going for the TT on Tuesday (as in 5 days).
I am appealing my insurance's decision to NOT cover, but in the meantime, I am going ahead with it. I just can't wait anymore and I can't take the chance they will deny me again after I put evrything on hold.
That being said, I can't thank you enough for all you courage, strength, determination and information. You are my hero and a BIG reason I am doing this.
Please tell me the pain is tolerable. I am shakin in my boots over here

[shackdog]

you go girl, fight the battle after it always easier when the stress is not as high

[aaamom]

Thanks Shackdog !!! I need all the cheers I can get right now !!!

[Telly]

Awwwww Aaamon! Wow girl. You worked so hard for it you should definately go for it. Pain is tolerable, after all I was walking about 7 or so hours after the surgery. Abs get really tight so sneezing hurts or laughing. Just be mindful that you will have a new belly and treat it with fragileness and respect.

You'll be just fine. You are the reason you are doing this. You are doing this because you have come very far and you've worked your ass off. You deserve this.

[chrispygal]

Good luck aamom! You'll do great!!!

[aaamom]

Thanks chrispy !!!!!!!!! Can you tell I'm a little nervous considering it's almost 2 am and I cant sleep !!!!!!!!

[NurseTeresa]

Good luck aaamom. Just relax and don't over do it in the beginning and if you have pain make sure you take care of that as well. Its time for some you time and some pamper time. Find yourself a little pillow or folded taped up towel that fits your abdomen all the way across and hold it firmly against your belly if you have to cough, sneeze or laugh! It does help alot. Hopefully you wont have an evil nurse like me who likes to make my patients laugh. Laughter is great medicine and helps them to forget some of what they just went thru. Make sure you do like Telly and get up and walk the day of surgery if at all possible. Don't have to walk a marathon but the ambulation keeps things from getting too tight and hurting so much worse when you fineally do get out the bed. Slow deep breaths help bunches too.

[aaamom]

Aww thanks nurse !!! I'm feelin' the love tonight !!
(not sure if I can be up and walking like Telly~she's just amazing)

Man I need to sleep, but it doesn't look like that's happening

[NurseTeresa]

Wish you were able to get some sleep at least some rest will help. You can always sleep afterwards. Telly is amazing! However, I have all the faith in the world in you that you can do it too! Just remember hold something against your tummy....breath in through your nose and out thru your mouth, eyes open so you can see where you are going(wouldnt believe those who try to walk with eyes closed its funny) and move. No marathon just slow little baby steps as far as you can go. Remember however far you walk out...you have to be able to walk back to your room to the bed. Will say prayers for you! You will be great!

[Telly]

Hey did you get it done yet? I think you did, if so, MAN! I've been gone for a bit. Please catch me up on this.

[NurseTeresa]

Hey I am with Telly! Where ya been? Please fill me in on how you are doing! Keep checking for posts from you...but so far NONE to no avail. Hope all is going well with you and that your having a speedy recovery!

[aaamom]

Hi Guys !

I have been posting, not sure why you can't find them. I did have my tummy tuck Tuesday (10/24) and arrived home Wednesday. The surgery was def more difficult than the band and I am still very very sore. In fact, I'm not sure why, but this was far worse than any of my hernia surgeries or c-sections. I hopefully will be getting my drain out today (yuck). Each day does get easier but I am impatient and cannot wait for this swelling to go down. And this incision is huge !!!! Thank you all for thinking of me !!! I am home recuperating and need all the encouragement I can get right now.
THANKS GUYS!!

[NurseTeresa]

Well, Welcome Back! Glad that you are home safe and sound. Take a pain pill before you go to have your drain pulled. Its not too painful just some discomfort. At least that is what the patients tell us when we pull their drains when its time. You will be fine. Just take it slow and pne day at a time. No one said you had to get up and run a marathon at this stage. Got your binder on? That should make a big difference also. Just think how fantastic you will look once the swelling goes down. The incision scar will fade with time also. Best of luck. Please keep me posted on how you are doing.