So these are a few things I've found out so far from annoying insurance providers for a little bit concerning GRS coverage I wanted to share...
Please remember that at the end of the day all of these insurance companies are just that, 'companies.' With the right case worker on your side and good dialog between you and the company, a lot of things are possible, especially in this case where it's obvious GRS certainly isn't cosmetic and most people know it's medically necessary. Most companies that I've looked into cover it in some form or another but only after certain criteria are met or proven like documentation from mental health professionals outlining their agreement to the validity of the patient's diagnosis.
For every diagnosis from a sore throat to knee pain to GRS, there's a code doctors and hospital billing offices use - these are called CPT codes, ICD-9 codes, etc. A good thing to do is call your insurance company and ask them for their, "exclusion list" that lists which conditions are covered or not. Once you find that GRS is not excluded you can go from there.
The most important thing is creating a dialog between you and your company before your surgery. I work in a hospital dealing with a lot of this every day and there's been so many instances of insurance providers denying coverage simply because they weren't notified or per-certified before the patient came in. Keep a diary of your interactions with your insurance provider. Write down who you spoke with, when, what they said, and ideas and stuff you have about solidifying your coverage. I write things like, "spoke with (name) and they talked about an exception to reimbursement percentage limits." There's been many times an insurance company has told me that they don't require per-authorization for so and so patient, then they later say they do, but I remind them of the name of their employee who said otherwise, and they then honor their mistake simply because I had that information. It's hard how ever to get a confirmation of how much they'll cover before your surgery. This is something I'm personally trying to do as I don't want to pay out of pocket for the whole thing, only to then have a small amount reimbursed.
I may be mistaken, but I don't believe there are any GRS surgeons who directly accept insurance. They only offer assistance in helping you with obtaining reimbursement from your insurance provider, and rightly so to cover themselves with such a variance in coverage or non-coverage between so many companies that patients could potentially have.
Where this creates confusion for insurance providers however is like someone mentioned above companies like to keep their customers within their network of approved healthcare providers. Like I've explained to my insurance provider, as none of the surgeons really accept their coverage, there theoretically then is NO network. And then, while they might say they do cover GRS, they actually can't directly cover it so it would then have to be through reimbursement. This then opens a can of worms of certain rules pertaining to reimbursements. Usually a reimbursement occurs when a patient visits an out of network physician, and then only a certain percentage is covered. However, like mentioned above with there being no network to work with, this then can become an exception to that rule and any other company specific guidelines they may have pertaining to reimbursements.
One thing to keep in mind though is that every company has different tiers of plans that then yield a certain amount of coverage for any kind of surgeries or inpatient visits. This might then create a problem where even though the company might agree to cover it through reimbursement, they might only cover whatever your plan normally allows. My plan covers 100% of any surgery costs no matter the cost once my deductible is met, but certain plans only cover 80% leaving the patient to cover the other 20% out of pocket, and so on. So as much as you want to watch if it'll be covered, you also want to see HOW it will be covered...
Hope this helps!
