Help Needed! I am about to fight with insurance!

[TXSara]

Hi everyone --

I had my GRS with Dr. McGinn in New Hope, PA on February 20th of this year.  My insurance covers GRS, but Dr. McGinn is out of network.  I have an in-network deductible of $3200 with an out-of-pocket maximum of $6k, and an out of network deductible of $6400 with out-of-pocket maximum of $12k.  My coinsurance for in-network is 20% and my coinsurance for out-of-network is 40%.

I knew going in that I would be paying more to go with Dr. McGinn.  I totally expected to hit the out-of-pocket maximum, and that I would only be reimbursed $9000 of the $21000 I had to pay for the surgery.

Today, I got word from my insurance company that the "maximum allowable expense" for this surgery is $4600.
 Since this is below my deductible, I get $0.  What a joke.  Obviously I'm going to appeal.

Here's how you can help me -- for any others who have had GRS recently and have the actual amounts paid, it would be extremely helpful to use your payments as evidence that $21000 is less than the maximum "fair value" for this type of surgery.

I'll likely be claiming that the insurance company is knowingly violating Chapter 541 of the Texas Insurance Code, but in order to do that I have to prove that their assertion that $4600 is a "maximum expense" for this surgery is not based in fact.  Rather, it is a made-up number used to avoid paying legitimate claims.

I know I'm asking a lot here -- I'm not sure, though, how else to get at REAL data.

Thanks for your help!

~Sara

[Jessica_Rose]

Although my surgery was over 5 years ago, my surgeon billed insurance for $21,170. My plan payed $12,702.60. If it would help, I can send a copy of the PDF with my name other identifiable information blacked out. Good luck Sara!

Love always -- Jessica Rose

[Maid Marion]

Do you have an Human Resources department at work that can help?

[TXSara]

Although my surgery was over 5 years ago, my surgeon billed insurance for $21,170. My plan payed $12,702.60. If it would help, I can send a copy of the PDF with my name other identifiable information blacked out. Good luck Sara!

Love always -- Jessica Rose

Thanks, Jessica!  I appreciate the help!

~Sara

[Nadine Spirit]

Egads gosh how I hate insurance! 

I have looked and looked and I cannot find my final totals, which bugs the hecky-hoo out of me. So I will continue to try and find the actual billed amount and paid amounts....... I wanna say my dr billed 100k and the insurance paid like 28k, but that is a vague memory. The amount your insurance is offering is laughable. Good luck.

[Lori Dee]

I don't know if this will help, but there was a study done to look at costs over time. They list a chart of average costs for various types of treatments (surgery and HRT).

Cost Chart

The main study is quite lengthy, but the link to it is here:

Costs of Care

I hope this helps.

Good luck!

[Nadine Spirit]

Okie Dokie, I found it!

My surgeon billed my insurance for two different amounts, one of which was $103,000, there was an in-network savings of 76k, insurance paid out $26,341.62, and I had to pay $658.38. The second billing was for $38,000, of which the insurance paid $34,200, and I had to pay $3,800. I don't have the EOBs for this stuff, it is on PDF printouts of the finalized claims. If you would like copies of it, then let me know.

[TXSara]

I don't know if this will help, but there was a study done to look at costs over time. They list a chart of average costs for various types of treatments (surgery and HRT).

Cost Chart

The main study is quite lengthy, but the link to it is here:

Costs of Care

I hope this helps.

Good luck!

Thanks, Lori!  This is fantastic!

~Sara

[TXSara]

Okie Dokie, I found it!

My surgeon billed my insurance for two different amounts, one of which was $103,000, there was an in-network savings of 76k, insurance paid out $26,341.62, and I had to pay $658.38. The second billing was for $38,000, of which the insurance paid $34,200, and I had to pay $3,800. I don't have the EOBs for this stuff, it is on PDF printouts of the finalized claims. If you would like copies of it, then let me know.

Thank you, Kelly!  I would love the printouts if you don't mind.  I'll message you!

Thanks again!

~Sara