Fees, finances and fights with insurance

Well, just one day left. Still not really nervous, just more anxious for it to happen. Plans for the day include my two pre-op appointments, one with the surgeon and one at the hospital with the anesthesiologist. After that... laying in supplies followed by dinner at a Brazilian Steakhouse, where I fully intend to eat my fill. But before that... a little talk about the costs of this thing.

I put a large down payment on surgery last month and I pay the remainder of my surgeon's fee today--at least, what they estimate insurance *won't* pay. The anesthesiologist and hospital bills, in contrast, have to get paid up front and in full, then they get filed for insurance refund later. So my credit card is going to take a heavy hit this week, but I should be getting a significant portion of it back. I'll certainly be well over my deductible and co-insurance limits after all...

Getting insurance approval...

 

...for this procedure was a four-month struggle. It always is for something like this, I suppose, but Aetna did everything they could to stall and make excuses. Several times they asked for the same stuff over and over, claiming they hadn't yet gotten them even though they'd been sent repeatedly via certified mail. Then they always seemed to take the maximum amount of time allowed to respond to new requests or materials, which I believe is 30 business days. Other times, they claimed they needed this that and the other out of the blue, forcing more tests or scans and resetting the clock... I got the impression that essentially, they were trying to run *out* the clock and make me lose interest or give up. Needless to say, that wasn't going to happen.

Since my insurance is through my company, I finally ended up getting my HR department involved, and funniest thing--my case got resolved that week and I got the Notice of Medical Necessity sometime in mid-February. Once that happened, the ball finally got rolling in earnest and I could schedule my braces. If the insurance estimates are correct, I'll end up paying about 1/4 of the total bill out of pocket. Painful, but doable; I've got enough in the bank that I don't need to take out a loan or anything, thankfully. Doesn't help that I'm out-of-network on this, but most of the good specialists are regardless of the insurance company you're with.

Braces

Getting my braces paid for has still not been resolved. My insurance has an $2000 orthodontics reimbursement rider, but it only applies to dependent children, not a 40-year old man seeking sleep apnea surgery. So we're going to re-file that under medical instead of dental, and see what happens.

 

Best advice I can give...

...after going through all this: what you need when you're facing surgery like this is a doctor willing to fight for you and not leave you to face insurance alone. For that reason, be leery of anyone who wants full payment up front, because they'll be less likely to do so. Thankfully, I had one who was willing to fight, though I wish I'd gotten HR involved a lot sooner. That's another lesson; don't be afraid to rattle cages and occasionally make a nuisance of yourself. This is your health and your life here, you have to stand up for yourself and not be railroaded by either insurance or a doctor.

This is not to say, of course, that there might not be some additional fights ahead, like over the braces. Sometimes insurance pulls stuff like claiming half the procedure (like moving the top jaw) is purely cosmetic and not needed for the sleep apnea correction so they won't pay. But if they try that here, they will be getting some nastygrams from both the surgeon and HR. Shouldn't be an issue, though. The notice of medical necessity included both the top and bottom procedures.