Question:
How to go out of network?

Aetna is denying the surgery for my sister with the same surgeon I had (who is out of network). They say there is 3 general surgeons in network who can do the surgery. SCARY. This is major surgery and she wants the BEST. Any ideas how we can get Aetna to approve for out of network?    — Diane N. (posted on December 30, 2003)

December 30, 2003
Out of network benefits are specifically for the purpose of using the doctor/surgeon you are comfortable with regardless of whether they are in or out of network. I went out of network with Healthnet and I just had to pay the out of network co-pay which was $300. You should call the insurance company back and ask them exactly what out of network means and why have it if you can't use it.
   — Jendeclan

December 30, 2003
I had Aetna and went out of network for both my surgeon and hospital. I had no trouble getting approved. Are you sure they are just approving the surgery in general, but not approving the surgeon? Just keep in mind that going out of network usually means that you (depending on your policy) will be responsible for your out of network % (mine was 30%) as well as the entire difference between Reasonable and Customary (R&C) charges and what the surgeon bills. Example - Surgeons bill - $5,000, R&C - $3,000, you will be responsible for the $2,000 difference as well as "your portion %" of the $3,000. With "my" Aetna - I would have paid $2,900. (2,000 + 900 {30% of 3,000}). From what my Human Resouces department told me, when it comes to going out of network, with our policy there is no true "out of pocket maximum" because you are always responsible for the difference between billed and R&C. I know this is rambling, but there are many people who get approved for the surgery and then are horrified when they start getting bills that they thought insurance would cover. Does your sister have the same insurance as you through the same employer? Is it possible that her policy is written differently? It really shouldn't make any difference since, like a previous poster stated, the purpose of out of network benefits is so that you can go to the Dr. you want, but you're going to have to pay more to do so. I would make sure that they aren't denying her for some other reason and then contact them and tell them you realize it's out of network, and you just want them to cover at the normal out of network rates - you realize they're not going to cover at the in-network rates. Good Luck.
   — Carolyn M.

December 30, 2003
Has your sister looked at using the surgeons that are in network? Be aware that just because they are general surgeons does not make them less capable of doing the surgery well. In my network, one surgeon that does quite a few RNY's is actually the head of the renal (kidney) transplant program! My particular surgeon is a general surgeon who is the head of laparoscopic and endoscopic surgery at a major teaching hospital. Just so happens he is the very best (IMHO) at lap RNY. Might save her lotso of money by staying in network. Just a thought.
   — koogy

January 2, 2004
Generally your insurance will tell you who is in network and who isn't. In network is a 'guideline' to keep costs down for you & the insurance company. A company has every right to have these 2 groupings. Generally, another doctor can become in network if they apply for it and are willing to adhere to the guidelines (pay scale & such). You would be quite surprised at what can be done. If the surgeon your sister wants is not willing to try to become in network ask him why. Usually they will tell you that either the plan doesn't pay enough or they just don't have enough patients from that plan to warrant taking a 'cut' in pay for so few referrals. In the end, it's what's most cost effective for the insurance company and the doctor. You might be surprised what the doctor will do if you talk to him directly...not his staff. Sometimes they are willing to write-off some (if not all) of the excess cost incurred by the patient. This is more likely to happen if your insurance company pays very close to what the surgeon would get from one of the companies he's already with. Good luck!
   — Diane S.