Who Starts the Insurance Claim?

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I had a call into Dr. West's schedule/cost guy (Eddie). A day later he phoned back. I wanted to touch base with him about Do's and Dont's when calling my insurance carrier before-hand about the surgeries. I don't do this everyday, he does. I didn't even know if it was necessary to account with the insurance carrier.

I know that verbiage and codes are everything with insurance claims and didn't want to hinder my objective of having this all covered as much as possible.

I found out that Eddie would contact my carrier himself. 

1. He would first go into the "prior-authorization" stage. He made it sound that this has to be done with everyone and every carrier. 

2.This may or may not lead him to the "pre-determination" stage. Sometimes carriers require it, sometimes not. (I do not know how a carrier determines if it's something they will ask for.)

This pre-determination state is sort of a submission of paperwork on behalf of the doctor's office. Remember those questions Dr. West first asked me in his office? Well guess what? His notes on that get submitted in this paperwork. You do the math on how important my answers were.

Eddie said it takes 30-60 days to hear back from the insurance carrier on this pre-determination submission. Of course I am praying that through some heavenly provision it will be much less than that. I told Eddie that, the more time that passes, the more expensive my plane ticket will be because of the holidays. (Eddie also has to put in a request to Dr. West for all his notes to put into the submission, which would take a day or so.)

On the phone Eddie was reading my records to himself. He jotted off 4 long medical terms for what would be done on my left foot. So I asked, "So that's the Brachy, the heel (bone extraction), the Bunion, and the Bunnionette, right?"

So you guessed it, the insurance company will see this as 4 surgeries. 4 claims. And the bills I will get will most likely be segmented between all sorts of things. You are treated specifically by an anesthesiologist for your 4 hour snooze, he/she is paid separately I hear.... things like that.

Here is a BIG question I did NOT ask, but will next time I speak with Eddie. Dr. West gives an approximate cost in his preliminary paper-packet introduction to all this. About $8000-$9000. It includes Hospital/Surgery Center, Anesthesia, Surgeon's fees, AND FOLLOW UP OUT WEST FOR 6 MONTHS. — My question is: "For the patients that stay the 10 mandatory days there, but then do all the post-op with another doctor back home, is the price less?"

To me and many of us, we would expect that is should be. I'll get back to you all on this.

I have to also pay all the fees for all the post-op at home through Dr. Yes. I wonder how many claims that will be into my insurance carrier... to see him every 3 weeks, have the cast removed, xrays taken, and a new cast put on... for 12 weeks. And he is listed as OUT-OF NETWORK for me. On average, doctor's in the East charge more too. Just a lot to chew on is all I'm saying... and pay. ;-)

NOTE: I have also thought that having one foot addressed at the end of the year is a benefit! Because then the second will be in a whole new year. I'm hoping that when it comes to insurance red-tape, that it will work in my favor with any annual limitation caps. 

It will however, not help me in the $250 annual deductible cap I have. Any deductibles I pay this year will not go towards that starting the new year. Oh well, can't have everything. ;-) (Now 10mo after the surgeries, I can tell you that it worked in my favor financially to have both feet address in the same year, because I then met my maximum out-of-pocket amount by the time I had the second foot done. This was not planned, but it happened that way due to scheduling issues at my surgeon's office.)

I hope all this information will help you in your surgery plans!

Tootles! ;-)

Insurance Coverage— Preliminary Steps

Hi all!

Although not planned, a moment presented itself for me to mention my potential surgery to my boss. I thought it would be unprofitable for me later if I didn't take it.

So now my boss knows surgery is probable before the end of the year and I will be needing to work at home post-op. Preliminarily, it seems fine so far.

So this leads to Insurance prep and scheduling.

First,

I went online to check my insurance coverage:

      1. I went to my job's "Benefits" online, and

      2. My insurance carrier's website

On my jobs benefit site:

-I verified my annual deductible-cap for the year (The maximum you will pay in deductibles annually.)

-What percentage of "out-patient" procedures my plan covers

-and other things like cost of generic prescriptions, etc.

In my Insurance carrier's site:

-I re-verified that Dr. West is indeed considered In-Network (YAY!)

-I discovered that Dr. Yes is considered Out-of-Network (not sure if this is really bad yet…)

I want to avoid big surprises later so I also went online to see if I could find articles about how to verify coverage (the smart way) with my insurance carrier. This was not easy to find.

So I decided I would call the person at Dr. West's office who handles cost and scheduling (we'll call him Eddie) to see if he could lend some Do's and Dont's before I call my insurance company to verify the coverage of these procedures. (Remember, if Dr. West is able to work on all three of the issues on my left foot that means it will be submitted as 4 different surgeries.)

So now I sit and wait for him to call me back. ;-)

Hasta luego!

My Neighbor is Moving ;-(

Awww. I found out a few days ago that Mark and his sister, my neighbors across the street, are moving! ;-( I mean I know I was planning on asking him to drive me to do groceries during my post-op, but I'm actually just sad they are leaving. Pooh.

Counting The Blessings!!

© Photo: Danielle Smith

All this "trying to provide information", is leaving out a very important aspect...

THE AWESOMENESS OF THIS WHOLE THING!!! I AM SO EXCITED! (I just work a lot of hours and don't have time to relish in it. I need to try harder.)

Ten years ago I was looking this up! (www.google.com was only 1 1/2 yrs old then!) And now I am closer than I've ever been to this corrective surgery. It is truly amazing. Money is an issue for everyone, but I did read that Dr. West has "special discounts and simple payments plans, including financing....." I'm sure other doctors have similar programs in place, too. So don't fret!

It's time for me to step back and realize that this is an amazing time for people with Brachymetatarsia. Hurray for us!

One of the biggest blessings in my situation is that I have family out west. That is a huuuge! My family can help me during the 10 first crucial days after surgery. Is God awesome or what?!?! It's one less thing to worry about, I can rest knowing that while I'm on pain medication I will be in great hands.

Woooohooooo!

When I get back home I will train my dog, Missy, to do the laundry! lol ;-)

“Fear less, hope more; eat less, chew more; whine less, breathe more; talk less, say more; love more, and all good things will be yours.”   —Swedish Proverb quote

How Will I Get Along After Surgery?

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I plan on emailing Dr.Yes this week to give the run down on why we are waiting, I want to remain on his radar. Once things are looking a little more secure at work I will email both Dr. West and Dr.Yes introducing them to each other. (I have to remember to ask each of them about their vacation times. I know that may be a bit personal, but I don't want to be disappointed later if I'm treated by a 'covering physician'. This is important.)

I have to call the finance guy at Dr. West's office to start tallying cost. I also have to think about the cost of the trip and travel reservations, cost & care for my dog, what do I do with my car so I don't get a ticket by the street cleaners while I'm away, etc. I also have to consider how food shopping and dog walking will get done post-op. (I live on the second floor. No elevator. I live alone.)

I have a stick-shift (car) and will be unable to drive it. (from what I've learned I can put no weight on my left foot.) (12 weeks. Uhg!) I'm thinking of maybe asking my neighbor across the street, Mark, if he could take gimpy-me to Whole-Foods once a week. ;-)

Oh gosh I just thought about Laundry too. (I have to go downstairs, then outside, to then enter the basement!) We'll see how it goes. God is very faithful and hasn't brought me this far to abandon me on crutches. ;-)

Wait a minute... I just had a thought... what if my insurance would cover such care? Heeeeeeyyyy, that's something I'll have to look into. I think it's sort of like an Rx from a Dr.(?) Saying you need this kind of care/help. (?) Hmmmmm. Brains churning now.

So again, I'm posting all of the details, good and bad, to help those of you considering this surgery. Especially if it's far from home. I hope it helps. Tootles!!

"All of life is a journey; which paths we take, what we look back on, and what we look forward to is up to us. We determine our destination, what kind of road we will take to get there, and how happy we are when we get there."  
                                    —From A Little Book of Happiness

Found a Dr. for Post-Op Care! YAY!

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While I wait some weeks for things to settle down with the changes at work (huge reconfiguring gong on, dunno what it means for my future), I figured I'd use my time wisely and try to find a podiatrist willing to do the post-op care once I return from my surgical trip out west. (Remember, Dr. West WILL NOT even schedule a surgical date without a willing post-op care physician in place before-hand.)

As you recall in my 2nd blog entry, I had several doctors reject me just for xrays, because I was honest and told them of my plan to have the surgery done by another doctor. Well, I depend on God greatly. I run to him in good and bad times, and so this little problem was certainly a time when I called on him.

I prayed. I asked God for help. I then put out an email to some friends asking if anyone had a fantastic podiatrist they could refer. I received a couple leads. One being from a girlfriend who is a Scrub. She called me to tell me she knew two GREAT doctors. However, when I told her the particulars, she told me what I've been telling you all. "No doctor wants to be responsible for another doctor's work." Even so, she said one of the two was a better candidate at saying "Yes" if she would explain that I was a friend of hers.

I don't like to count my eggs before they are hatched but "Hallelujah!" He said 'Yes'. I emailed him two weeks ago to thank him. He responded, "I have two people currently in my practice that we performed the lengthening on, so I am comfortable managing things post-op. I will have no problem calling Dr. West to discuss your case as well."

By now you know I'm a thinker and researcher. Normally I'd see him, ask him tons of questions, want referrals.... but there is such a thing as pushing your luck, so even though it is just about NEVER wise to have a doctor work on you without preliminary review... I'll take my chances considering the trouble I've had and his willingness. He (Dr. Yes ;-) was a positive referral! (and it's not for the surgery itself!)

Tootles. By the way, thanks for following this Blog! ;-) I need all your support out there!