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! ;-)