Good News, Bad News...Do you hear a train?

Well, I had a call from Dr. Houston's office today that I have been approved by my insurance company and my surgery is scheduled for Sept. 4th.  That is the good news and I am very excited at the prospect of finally having my surgery.   Now for the bad news... I checked with the insurance clerk at their office when I first began checking into the surgery and was told they were participating providers.  Last week when I saw Dr. Houston I found out that he is an out of network provider.  I would have thought that would have been made clear up front but was told that they were just telling me that the hospital was a participating provider.  Today I called my insurance compahy to verify what my expenses would be and was told by the contact there that she could not find any evidence that Centennial is a participating provider.  I asked about the $2,000.00 maximum out of pocket expense and was told that they pay only 70% or usual and customary and the physician and surgeon and I suppose anyone else can charge me the other 30% as well as any other expenses they charge, so if, for example, Dr. Houston's office charges 7,000 for the surgery, the insurance says they will pay 70% of 5,000 and I am left to pay the other 2,000 plus the 30% of the 5,000 that is not covered (1,500) and then the same holds true for the hospital, the anesthesiologists, and the radiologists.....I don't know what to do.  Seems like just when I thought I was seeing the light at the end of the tunnel, I'm hearing a train whistle!  Anyone have a similar experience or any feedback, I would sure appreciate it.  I love Dr. Houston and really want to have him as my surgeon, but I can't handle this uncertainty as far as the financial part of the surgery is concerned. 

Sounds pretty confusing to me Kathy!

My out of pocket max 1500. Once I reached that, insurance paid 100%. Since I hadn't met that yet, I owed something around $1000.00. I was always under the assumption that you pay out of pocket until you meet your deductible and then the insurance company covers a certain percentage and you take care of the rest. And once you pay out of pocket to meet your out of pocket maximum, then the insurance company pays 100%.

I know the insurance ladies at Dr. H's office are pretty awesome. I'm sure if you ask them to break everything down for you and to double check coverage, they'd be more than willing to do so.

 Good luck!

Thank you so much for your response.  I can assure you that the more I check, the more confused I become.  I know I will be having several more discussions and getting more stuff clarified in the days ahead.  I am basing the information I have on my conversation with Holly, Cheryl, and the contact with Humana.  My concern is that after the reasonable and customary charges are paid, I may have to come up with the difference to pay not only the 30% I will owe, but whatever amount is above the r/c charges at 100%.    I could see that becoming a nightmare very quickly.

Kathy: I'm so sorry for your troubles!  I think that Sheila had the same thing happen.  I feel sure that she will be online later.  Have you inquired about which doctors and facilities will accept your insurance?  I had mine at Baptist (I have CIGNA insurance) and I love my surgeon.  I have also heard good things about Vanderbilt.  Just curious if maybe there are other doctors that are approved providers. Good Luck! Freddie

Freddie, Thanks for your concerns.  I hope that if there is anyone out there who has had a similar experience that they'll let me hear their resolution.  I live in Kentucky and there is a bariatric surgeon in Evansville, Indiana (10 miles from here) who is covered by my insurance and I have contacted a physician in Louisville as well.  I really don't want to switch surgeons as I have been quite impressed with Dr. Houston, but the whole thing kind of takes on a nightmarish quality when I get to thinking about what could happen. 

I'm so sorry you're having such troubles! First of all, I agree with April, the girls at Dr. Houston's office are awesome about getting you taken care of with your insurance, copays, etc.... My out of pocket was 2000.00 and Dr. Houston was out of network for me but the girls in his office worked with me and I was out only @ 1500.00. They will work with you. Don't get discouraged. IF you want Dr. Houston as your surgeon then that's what you should have. Don't just settle. You are worth the fight! (((HUGS))) Janie Dr. Houston  3/19/2007 304/235/160

Have you checked to see if Baptist is in network for you? I can highly recommend Dr. Spaw and the Baptist team. I went to seminars at 3 different hospitals before I chose Dr. Spaw. I knew he was right for me immediately.

Hi Kathy. It does sound like he is out of your network so you are going to have to pay 30% of the cost of the surgery. You may want to consider changing surgeons. If you do not want to, then you need to ask the Insurance people at Dr Houstons office what the cost is for the surgery (after the insurance deductions) and how much your portion is. Vanderbilt was able to tell me upfront. Of course that can change if there are any complications or extra days in the hospital but for the most part, they can give you an estimate. Your portion may be less that you realize. But I think that is a decision you have to make. Weather or not you want to change surgeons or pay the cost. At least you know you are approved and are getting surgery no matter who you go through. That is Great news. Good luck with your decision.

Be careful, but I probably don't have to tell you that. Even for smaller things such as the hubby's ER visit and MRI, the 80% out-of-pocket that I was paying with BCBS added up in a BIG hurry. While I know that it is important to feel comfortable with your physician, there are quite a few good ones around, and surely there is another that would be worth a visit.

Thanks for your reply.  I just was hearing one thing from Centennial Center, another from the surgeon's office, and yet another from Humana.  I did some more checking and found that one of the docs in the group is a participating provider with my insurance company.  I have contacted them and have an appointment to meet with Dr. Dyer Tuesday.  Since I have already met all the criteria and have been approved for surgery I am hoping that this will just be a minor setback.  I feel that in checking their credentials both surgeons are highly trained and qualified.  Dr Dyer has more years of experience with the bariatric surgery and has done more procedures, so hopefull this is just a message from the good Lord letting me know that I needed to get some things resolved and this will hopefully be the resolution.  The Centennial Center is a Center of Excellence as is the hospital, so I'm going to hopefully resolve my conflict and be ready for surgery soon.  Looks like your surgery has been a successful!  I hope I will do as well.  Thank you again,  Kathy