help -- plastic surgeons refusing to submit to insurance!!

I have a large incisional hernia that needs repaired, and I have a very large panni that is causing all sorts of problems.  My PCP believes that the panni removal is necessary, and I meet my insurance company's requirements for medical necessity based on their clinical policy bulletin. After spending ALL day on the phone Friday with the offices of the plastic surgeons that my RNY surgeon works with (I planned to have her do the hernia repair), and then the offices of all the rea PS's that my insurance covers, NOT A SINGLE ONE OF THEM will submit an insurance claim for a panni removal even if I get the procedure pre-approved by the insurance company based on info from my PCP and/or RNY surgeon!  Even the one surgeon who could/would do both the hernia repair and panni removal himself would only submit a claim for the hernia repair! Clearly this has NOTHING to do with cosmetic versus medical necessity.... it is a matter of the PSs not wanting to accept what the insurance company will pay for the prcoedure!  (Otherwise, they would be willing to do it if I had it pre-approved.) I don't understand how a surgeon can sign a contract with a PPO (in which they agree ot the PPO's rate structure) and then REFUSE to provide a service covered and approved by the insurance company!  How can they get away with getting the PPO patients for the procedures where the reimbursement is adequate yet then refuse to provide services where it is not?!? My insuracne company told me the best thing they could suggest was to get the surgery pre-approved, pay the full fee myself (!) and then submit the claim myslef (but then that means that I am still apying the PPO-paneled surgeon his full fee not the network negotaited fee... so how is that different than the surgeon asking me to pay the difference between his full fee and what the PPO pays is HE submits the claim?!? I plan to call Aetna back MOnday and ask to speak to someone in their complaince unit, and will contactc my RNY surgeon to see if she can assist in any way, but other than either trying to get Aetna to tell ME which one of their surgeons will do the procedure or trying to find someone in another city who will do both procedures, I'm not sure what else to do. Lora

Somehow I wouldn't want to "force" a surgeon to do my surgery.  OK, they would probably do a great job if the insurance company said they had to do the surgery but I would be very nervous. You might have to go to another town.  Not that that would be easy.  I traveled two hours from the Dallas area to a smaller town with an excellent top rated surgeon who did my RNY as well as my panni.  I would want to go to a surgeon who wants to do my surgery.  Perhaps the insurance companies are not paying enough for a panni.  Mine took twice as long as my RNY and I ended up with a staph infection with a one week hospital stay.  The one thing you could do is discuss this with your PCP and they may call the doctor they recommended as the plastic surgeons rely on referals from PCP's and they would want to maintain a good relationship with them maybe even moreso that with you. Jim Randall

Hi Lora,  I am in Northeast Ohio and am in the process of trying to get TT covered under my health insurance, Anthem  BC/BS  (Blue Preferred Primary).   I have letters from my chiropractor and primary care documenting medical necessity and I feel hopeful about that (not too hopeful, I must add : )    I agree, it is hard to find a PS who is willing to even TRY to get insurance to cover it, and you are RIGHT.  It's all about the cash cow, the self-pay patient.  I have been fortunate to find at least one PS who is willing to submit all paperwork, and two more that have said if I can get it approved, they will cover.  It is frustrating to hit so many stumbling blocks along the way, but it seems that is what the insurance and plastic surgeons do--- put so many barriers up that you give up and pay for it all yourself.   I just recently moved to Ohio, but wonder if there is a state insurance commission that they all have to answer to.  If nothing else, Aetna should be made aware that they have doctors who are refusing to submit patients claims-- that should be a violation of the contract they agreed to when Aetna signed them on.  Let me know how you make out and I will do the same.   Good Luck! Kathy