Insurance Guidelines - A member's experiences and observations - Kristi Griffith

Here is what I've learned:

  1. The best insurance to have (if you have a choice), almost no matter where you live, is the Blue Cross/Blue Shield PPO plan (Blue Cross pays the doctors, Blue Shield pays the hospitals).

    Even if you're out of state, most states participate in a nationwide network so that you can go to any preferred provider and you're treated like a regular, in-state member. For example, UPMC is a PPO hospital with a contract with the local (Pittsburgh) Blue Shield. But even though I'm from California, UPMC just bills the Pittsburgh Blue Shield for my treatment, and then Pittsburgh Blue Shield bills my local Blue Shield. I don't think many other health plans provide national coverage in this way.

  2. If you have an HMO, don't despair, but it will take some work. After speaking with a hospital administrator friend and others, I'm convinced that everyone can have their MVD with the doctor of their choice if they're persistent.

      Here are a few tips for dealing with an HMO:

    1. Get someone (in order of preference, a local neurosurgeon, a neurologist, your primary care physician (PCP), or an employee at your PCP's office) to be on your side. If you have a health care official supporting you every step of the way, your case will move along a lot faster.

    2. Provide that someone with as much data as possible. If you have information to show how the outcomes with doctors who use intra-operative hearing monitoring are vastly better, use it. Use your information to show that the neurosurgeon you want has fewer re-dos than other doctors do. Get additional data from the neurosurgeon you want. He/she should have outcome data showing how much better his/her patients do post-operatively. You want to show the insurance company that by going to the best, you will ultimately save them money, because you will likely not have hearing problems and you will likely not need a second surgery.

    3. Use the hearing issue in as big a way as possible. I'm bilingual and work in a bilingual office, so I was advised to explain that if I had hearing loss, I would lose my ability to work effectively. Thus, I was told to show why I was a "special case" that required the utmost attention to preventing hearing loss. Ultimately, I think most jobs require effective hearing to one degree or another, so play it up as largely as you can!

    4. Write to your congressional representatives and your senators.

      A person I know told me that Senator Barbara Boxer (CA) is the person who "did it" for her. Senator Boxer wrote a personal letter to her insurance carrier, and suddenly she was approved for her out of state surgery.

    5. Don't give up. It may take a long time (be prepared) but if you're persistent, I am convinced you will ultimately be approved. It's the old "squeaky wheel" idea.

    To continue on my insurance information, let me re-iterate two things:

    1) The best insurance appears to be the Blue Cross/Blue Shield PPO plan. Almost no matter where you live, you will likely be covered for the vast majority of fees under this plan (as long as your provider is a "preferred provider."

    2) If you have an HMO, you need to fight, but I believe you will ultimately win. If you have Aetna HMO, especially, in California, you should fight, because we already have a member who was authorized. If she was authorized already I believe it would be discriminatory if you were not.

    Here's some additional information (regarding "out of network" coverage):

    Briefly, if you are on a plan that offers some percentage of coverage for out of network doctors, YOU WILL STILL NEED TO FIGHT. Because you are out of network, your insurance has no contract with the provider. Thus, the provider charges what it wants to (approximately $40,000-$45,000), and your insurance pays what they want to (under my PacifiCare plan, an estimated $20,000-$25,000). So even though PacifiCare said they would pay 70% of costs and my maximum out of pocket was $3,000, those numbers only apply to THEIR fee schedule. So I would pay 30% of their $20,000 fee schedule to a maximum of $3,000, but then I would be liable for the entire difference between their $20,000 authorized fees and the hospitals $40,000 bill.

    HOWEVER, there are two options:

    The first is to ask for the health care provider's help in obtaining a one-time contract with the insurance provider. Specifically in my case, there was a woman at UPMC whose job it is to make contracts with insurance companies. She said she was "sometimes" successful in obtaining a one-time contract with insurance companies on behalf of people who are using out-of-network coverage. (So in my case, UPMC would have a special one-time only contract with PacifiCare for my MVD). I didn't get the details, but my guess is that the hospital persuades the provider to pay fees higher than their normal "usual and customary" fee schedule, and the hospital compromises by giving the insurance company some kind of discount. If the insurance company agrees, you're no longer liable for the "differences" in fees vs. "billing", because all of the costs have been pre-negotiated and mutually agreed upon.

    It may seem unlikely for an insurance company to do this, but the hospital representative explained she has a fairly persuasive case. She provides the insurance company with data showing Dr. Jannetta's (Dr J. was still at UPMC at the time) success rate, and showing his low "re-do" rate. She tells them that if they'll pay for this one-time operation, they will likely not have to pay any more for tests, drugs, or additional operations. Additionally, I told her to tell them if they didn't authorize it in this way, I would fight for full payment through my HMO and they would have to pay the entire fee (no discount). The key is to persuade them that negotiating now will actually save them money in the long run.

    The second, rather unpalatable, option is to "roll the dice" and accept responsibility for whatever cost differences between what the insurance will pay and what the facility will bill. But even if you are willing to take on that responsibility, you should really tread carefully. We all expect to have a successful and "uneventful" surgery, but even small complications can extend your hospital stay, and you will be paying thousands of dollars for every extra night in the hospital, and every test that is performed. In reality, the hospital will probably negotiate some sort of reduced fee with you, but I was told they would NOT do this up-front. It has to be done after all fees are incurred. But who wants to worry about fees and negotiating after surgery when you are trying to recuperate? Thus, I was strongly advised NOT to go to an out of network facility under those conditions.

    So that's it for now, but I think it covers the three main types of insurance: HMO, PPO, and out-of-network. If anyone has any questions, just send me an email. You may get my email address from the Members page. If anyone has any statistics or other information that might be helpful to those fighting their HMO's, please send them to me, so I can supply them to others in need.

    Permission granted the HFSA to post my Insurance Guideline information on website.
    Kristi Griffith, September 21, 2001