Heartbroken

[glennstanzalone]

Hello, I've been consulting with Dr. Sabol in Arizona for the past 5 years. Every couple years when I get new insurance I try to get it approved with no success. I really really really thought this would be the time. I got Blue Cross through the healthcare.gov marketplace, he's contracted with them, all procedure codes are covered.....then I walk in to their office and they tell me that, get this....

They are ONLY contracted as a Blue Cross PPO Provider. NOT HMO.

But Blue Cross retired all individual PPO plans this year! I can't even buy one!

I will have to pay 20K out of pocket or get hired at a place with BCBS PPO and no orthognathic exclusion. Feels like winning the lottery would be more likely. NO Healthcare marketplace plans cover out-of-network providers except United and they will only cover 50% of the surgery if I can even get approved in the first place.

I took a job in 2013 that had BCBS insurance and they switched to United within 3 months of working there. United denied me then because my job specifically excluded the surgery from coverage.

AM I CURSED OR SOMETHING?! This just seems f***king insane. I don't have the credit score to "finance" it and I can't save 20K. WHO CAN SAVE THAT MUCH?

I've been crying on and off all day. I just had to get it off my chest.

[glennstanzalone]

Also, I spoke with their front office that "Well you know you are losing a patient pool of over 37,000 ex-PPO members and however many new HMO members, would you ever consider changing your contract to accept the BCBS HMO?" They said they would discuss it at their weekly meeting. I talked to like 3 receptionists there. They were so nice and caring. I feel so flower awful.

[snapdresser]

Sorry to hear about your experience with the insurance battle I know many of those on this forum have had similar experiences. I understand that you like Dr. Sabol but there was a surgeon I liked too and I went through a couple consultations with but simply couldn't use in the end because he didn't accept insurance. Have you tried looking for an in-network (BCBS HMO) surgeon to try and get it approved? I know it's not ideal, but it's what I did and I'm very pleased with my results, and thrilled that I got it done when I did! If I had waited to save up for the surgery, that would have taken years, I'm sure.

[bbsadmin]

Is Blue Cross the only company that would have totally covered your procedure? Are there any others that you could investigate, other than United Healthcare?

In general, I think that insurance companies are offering less and less coverage to people. I'm not surprised to hear that United will cover 50% (IF you can get approval). You'd be lucky for them to cover anything, IMO. If you can get them to decide that it's "medically necessary" you might have a better chance (as opposed to the procedure being considered "elective.")

I'm sorry to hear about your frustration. It reminds me of a situation I was in a few years ago. I needed a specialized hip surgery and the leading doctor in the field (who happened to be in my area) didn't take insurance. It would have cost me $40k out of pocket. Fortunately, I found another excellent surgeon who could do the procedure and accepted Blue Shield PPO -- and because I'd met my deductible that year, the surgery cost me nothing!!! It seemed like a miracle, because for months before I found that surgeon, I was very depressed about my situation.

[glennstanzalone]

Thank you guys for the support. It's been a long road and it's nice to hear other people have experienced similar frustrations.

I'm going to call Blue Cross and see if any HMO providers can do orthognathic surgery. I'm just so worried about going to a sub-par surgeon and having my face destroyed. I know, dramatic, but it IS my face after all.

I have looked into other companies (aetna/signa) but most won't cover it unless it's extremely severe & congential or a result of trauma. The BCBS plan I have right now is great because it's subsidized by the govt and I have like a $700 out of pocket max for the whole year. I was trying to get the surgery for that little. Too good to be true, I guess.

I'm going to keep my head up and keep trying. I just can't believe insurance companies are doing this to people.

[samoorelaw]

I got UHC to cover 50% after two appeals, when they finally acknowledged it was medically necessary. Just don't give up! Appeal, appeal, appeal! They'll do anything to get you to go away if you fight hard enough, since most people don't put up a fight after getting denied. I was told that as a matter of course, most insurance companies deny you the first time, more than likely in the hopes you won't question it. Don't let them get away with it!

[glennstanzalone]

Great news everyone!! I spent almost 2 hours on the phone with BCBS getting the names of all surgeons in my area and the rep decided to escalate my issue. A wonderful nurse reviewed and forwarded to the contracting department; she asked if they would make an exception for me due to the limited number of providers in my area. The Blue Cross contracting department agreed, contacted Dr. Sabol and offered to contract with him as an in-network provider for me. On friday afternoon, BCBS called to let me know Sabol agreed! The paperwork will be finalized next week!!

Dr. Sabol's office was in the midst of having a meeting about my case anyways to see how they could work with the insurance company but miraculously, BCBS approached them. Which is beyond amazing.

So now all I have to do is go to my ortho consult, and then get BCBS to approve the inpatient stay for the surgery. They already let me know Sabol's preferred surgery center is in-network so I have to see what they actually need to preauthorize.

Anyways, thank you all for your support. I will keep you all posted about what happens next. This can be so hard to navigate alone!

[snapdresser]

That's awesome!!! That was really cool of Dr. Sabol to accept your insurance's payment. Many high end surgeons think the insurance reimbursement rate is too low. Very excited for you!!!

[drbartikii]

hey heartbroken what happened? why upset?

[A40js]

Have you had the surgery yet?