Insurance PreAPPROVAL!!!!

This is a bitter sweet entry.

Today, 6 weeks after Eddie submitted the paperwork for Pre-approval, I decided to leave him a message to check in. Afterwards I sent one email to both Dr. West and Dr. Yes (CCing Barbara). (If you want to know who's who among these names just click on the green "Cast of Characters" link in the right column.)

I was just FYI-ing both doctors about the pre-approval so they would know why things weren't moving forward. (I expressed my disappointment.) Having never met Dr. Yes, I wanted to stay on his radar. The email of course would serve both doctors to now have each others' contact info so they can begin to communicate about the procedures and post-op care as they need.

Coincidentally, only 5 hours after sending that email, Eddie called me to tell me the insurance had just faxed over the approval. Amazing! lol.

So here's the conversation:

Eddie: "So your insurance will cover this surgery."

Me: "Well wait, there is more than one surgery? It's four surgeries right?

Eddie: "Yes, Brachy, Bunion, Heel and Bunionette. But they approved only the Brachy and Bunion. The other two don't need pre-approval. So do you want to schedule this then?"

Me: "Thank you. Eddie I think you know by now that I'm a 10 question sort of person. (giggling) So I really need to get things clear before going ahead and doing this. I have a lot of things to organize and arrange. The flight, the care for my dog, my job, etc. So my insurance will only cover 90% correct?"

Eddie: "Yes that's right. The approval isn't a guarantee of coverage either, as this isn't a claim being submitted."

Me: "So do you all bill your clients for portions not covered by insurance?

Eddie: "Yes"

Me: "So when is that arranged? I don't really want surprises later and I want to be responsible. I don't have credit cards. I want to be able to pay in installments. Can I do that?"

Eddie: "Yes"

Me: "Do you charge interest?"

Eddie: "No."

Me: "OK. Because I do not want to take out a loan for the balance. My credit score is very very good though. I like paying me bills before they are due."

Eddie: "Well I could give you a close figure, but not exact."

So we agreed he would get me a close figure by end of week.  
Here is the BAD NEWS!

He told me that we would have to schedule in FEBRUARY of 2011!!!!!! I nearly fell off my chair! That's 3 months away! (It's already been 4 months with all this xray and going back and forth stuff) I told him I was very surprised and disappointed. He explained something about the holidays being on particular days and therefore they really lose almost half of December.

When our conversation was done I realized I had just sent an email to my doctors informing them of the insurance hold-up. So now I had to send them the news of more hold-up and why. (of course you realize that I'm emailing Dr. West who will know all these happenings from Eddie and Barb. But just in case the communication gets lost in the shuffle at their office, I'm informing him as if he didn't know) Again I expressed my disappointment in the email.

More than not wanting to pay for a Holiday-priced plane ticket, I wanted to get the left foot onto the 2010 papers. This way I would have no problem with the right foot on the 2011 papers. (Both in the same year.... I'm thinking I may reach some sort of cap or something?) (this concern turned out not to be a concern. It turned out to be more profitable for me to have both done in the same year.)

Anyway, so that's that.

One last thing. Dr. Yes answered my email right away. Just a reply to me though, not a "reply all". He shared his availability schedule with me because I had asked him to. So I know what month not to book the surgery. He also shared an interesting little thing with me:

"Incidentally, 30-60 days seems awfully long to get a pre-cert. Usually here in the East it takes 7-10 days at the longest, with most insurances within 72 hours."  ...hmmmmm.

Next steps:

I will discuss the estimated balance with Eddie by end of week. Then I'll have to shuffle things on my end to align my time off, dog care, see about flights, blah blah... then call Eddie back. Hopefully by then the two dates he gave me for February aren't taken. I'll schedule the surgery, THEN book the flights. ;0)

Let's see what happens... would be nice if after receiving my email Dr. West would find a date this year. But truthfully, everything has its time so I'm ok with February. There may be unforeseen blessings in having it then. ;o)


Tootles... 


pst...CHRISTMAS IS COMING!  ;o)

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WAIT! WAIT! WAIT!

I thought I was done— sorry! I logged off and sat to read my snail-mail. I just received a letter from my insurance carrier. The postmark on the envelope is Nov 3rd. The letter inside says, Oct 29th. (So does this mean that Eddie would have contacted me today regardless of my call into him and my email to Dr. West? I think this shows that it is a possibility.)

The envelope has my address on it, but the letter is written to Dr. West. My insurer sent me a copy. It says (verbatim):

Dear [Dr. West]:

We received a request for a voluntary predetermination of coverage for [patient's name] for the following service/procedure(s):

• Surgical Procedure Foot-Toe Brachymetatarsia Correction 28899-LT

After reviewing the information submitted we have determined the service/procedure(s) to be medically necessary and a covered benefit under the member's plan.

This voluntary predetermination of coverage decision is not a treatment decision, a medical consultation, or claim approval. In providing this predetermination information [X-Y-Z insurance] does not guarantee the service/procedure(s) will be covered. Claims submitted will be paid in accordance with the member's eligibility status and all benefit plan provisions in effect at the time the service/procedure(s) is actually rendered. All rights and obligations under the benefit plan are reserved.

If you have any questions.. blah blah.

I just wanted to share that with you. There are those of you who have always wondered about these dealings with insurance companies. Well this is one example of how it's being handled by one of the top insurers in the US. Bottom line? It's a risk no matter how much you try to plan, or figure you deserve the coverage for paying your insurance for years without a claim. Even after surgery you can be denied. That makes my heart sink.  ;o( Gulp.

But at this point, I'm willing to take the risk. VIVA LA VIDA! ;o)

(wooooo whoooo.. did you catch that by the way? "Medically Necessary"! I have to cry at this. It's like someone saying, 'Yes I understand your pain'.  ;o)

OK. I'm really going this time.