Surgery's in 5 days but unable to pin down insurance estimate. Help!
July 8, 2018 8:57 PM Subscribe
I (33, F) am getting my tonsils out in 5 days and I'm still trying to get a sense of the financial burden I'll bear afterwards. I have been at this for 1.5 months, with numerous back and forth calls between the ENT, who's based in Washington, DC, and my insurance (Anthem BCBS of Connecticut; I live in CT). I'm getting conflicting information from both, not to mention uncertainty about hospital fees. What do I need to ask/do to wade through this and get as accurate of a financial estimate as possible? This shouldn't be THIS hard.
The kink is that my plan--supposedly quite comprehensive (Gold Century Preferred PPO Tiered 2000/0%/5500)--is just that, TIERED. This is completely new to me, the ENT's office, and apparently to every Anthem representative I've spoken with. So even if providers are in network, they're tiered. Tier 1 has a $2000 deductible, whereas Tier 2 has a $4000 deductible (I've had nothing go to either deductible yet). I've confirmed with an Anthem rep that there's nowhere I can see provider tier assignments--I've always had to call Anthem. That said, Anthem's reps have been wrong before about the tier assignments (case in point my PCP--I was told Tier 2, which has a $40 copay, but the provider said they're Tier 1, with a $20 copay, which is what I paid). This is now happening with the ENT--Anthem's rep told me the ENT is Tier 2 while the ENT says they're Tier 1 AND they got confirmation from Anthem that my responsibility would be the $2000 Tier 1 deductible and that's it. What do I have to say to get correct info about this from Anthem? I have a reference number from the ENT's office, so my plan is to call Anthem, reference it, and go from there in order to get it in writing. Right? Is there anything else I should say to get the real deal on this? Ask to speak with a manager/supervisor?
Problem #2: Anthem has told me the hospital I'm having surgery at is Tier 2. I don't trust this, but the hospital itself only gives you an out of pocket estimate and a CPT code and kindly said I needed to figure out a cost estimate with my insurance. So looks like I have to be my own advocate here, but again, i don't trust the veracity of the information Anthem has given me, so I feel stuck. Should the hospital be making more of an effort? What party typically does this?
Question #3: Assuming I'm responsible for figuring out insurance coverage for everything related to this surgery, do I need to get a CPT code for everything that will be done at the hospital and run it by my insurance? I read after furious research tonight that I should ask the ENT's office for a list of the providers who will be involved in doing my surgery. So if I understand it correctly, I need to first get this list, then call Anthem and make sure those providers accept my insurance? But there we go again with the tier debacle.
Potential insight: I'm wondering if part of the problem is that my card says that providers should file claims directly with the local BCBS plan. Since I'll be having the surgery in Washington, DC, I'm wondering if they have no tiered plans. Would this local billing negate my own plan? Do I need to research whether Anthem has tiered plans in DC? UGH!!!!!!
If you couldn't tell, I'm on a fairly tight budget, and this tier nonsense has the potential to triple the cost of what I thought I would be paying for this surgery, i.e. if the ENT is Tier 1, and the hospital is Tier 2, that's two different deductibles I'll have to meet ($2000 Tier 1, $4000 Tier 2). I thought the surgery would cost $2000, so if it's actually $6000+, I can't afford that right now, not to mention possible balance billing and coinsurance. Basically I'm afraid I'll be socked with a bill that is insurmountable, so I want to do my due diligence in figuring out costs ahead of time and determine whether I really can afford this.
Thank you for your help navigating these nasty waters!! Cue the rants about the state of health insurance in this country...
The kink is that my plan--supposedly quite comprehensive (Gold Century Preferred PPO Tiered 2000/0%/5500)--is just that, TIERED. This is completely new to me, the ENT's office, and apparently to every Anthem representative I've spoken with. So even if providers are in network, they're tiered. Tier 1 has a $2000 deductible, whereas Tier 2 has a $4000 deductible (I've had nothing go to either deductible yet). I've confirmed with an Anthem rep that there's nowhere I can see provider tier assignments--I've always had to call Anthem. That said, Anthem's reps have been wrong before about the tier assignments (case in point my PCP--I was told Tier 2, which has a $40 copay, but the provider said they're Tier 1, with a $20 copay, which is what I paid). This is now happening with the ENT--Anthem's rep told me the ENT is Tier 2 while the ENT says they're Tier 1 AND they got confirmation from Anthem that my responsibility would be the $2000 Tier 1 deductible and that's it. What do I have to say to get correct info about this from Anthem? I have a reference number from the ENT's office, so my plan is to call Anthem, reference it, and go from there in order to get it in writing. Right? Is there anything else I should say to get the real deal on this? Ask to speak with a manager/supervisor?
Problem #2: Anthem has told me the hospital I'm having surgery at is Tier 2. I don't trust this, but the hospital itself only gives you an out of pocket estimate and a CPT code and kindly said I needed to figure out a cost estimate with my insurance. So looks like I have to be my own advocate here, but again, i don't trust the veracity of the information Anthem has given me, so I feel stuck. Should the hospital be making more of an effort? What party typically does this?
Question #3: Assuming I'm responsible for figuring out insurance coverage for everything related to this surgery, do I need to get a CPT code for everything that will be done at the hospital and run it by my insurance? I read after furious research tonight that I should ask the ENT's office for a list of the providers who will be involved in doing my surgery. So if I understand it correctly, I need to first get this list, then call Anthem and make sure those providers accept my insurance? But there we go again with the tier debacle.
Potential insight: I'm wondering if part of the problem is that my card says that providers should file claims directly with the local BCBS plan. Since I'll be having the surgery in Washington, DC, I'm wondering if they have no tiered plans. Would this local billing negate my own plan? Do I need to research whether Anthem has tiered plans in DC? UGH!!!!!!
If you couldn't tell, I'm on a fairly tight budget, and this tier nonsense has the potential to triple the cost of what I thought I would be paying for this surgery, i.e. if the ENT is Tier 1, and the hospital is Tier 2, that's two different deductibles I'll have to meet ($2000 Tier 1, $4000 Tier 2). I thought the surgery would cost $2000, so if it's actually $6000+, I can't afford that right now, not to mention possible balance billing and coinsurance. Basically I'm afraid I'll be socked with a bill that is insurmountable, so I want to do my due diligence in figuring out costs ahead of time and determine whether I really can afford this.
Thank you for your help navigating these nasty waters!! Cue the rants about the state of health insurance in this country...
Try to get documentation on this tier nonsense in writing from both parties. Does the doctors office have something in writing from the ins co that says what tier they are and ask the ins co to give you all of this in writing too.
posted by bleep at 10:05 PM on July 8, 2018 [1 favorite]
posted by bleep at 10:05 PM on July 8, 2018 [1 favorite]
If you couldn't tell, I'm on a fairly tight budget, and this tier nonsense has the potential to triple the cost of what I thought I would be paying for this surgery
Medical debt is not like other debt, in that a) it is unsecured (they cannot put your tonsils back); b) it is highly negotiable; c) portions can be forgiven; d) payment plans commonly extend for decades. Have the surgery you need to have and deal with the debt after. It's likely to take weeks if not months for all of the bills to roll in to see the total anyway. Whatever the total, you should always negotiate the portion "not covered by insurance" anyway. Some billers delete it!
posted by DarlingBri at 3:12 AM on July 9, 2018 [8 favorites]
Medical debt is not like other debt, in that a) it is unsecured (they cannot put your tonsils back); b) it is highly negotiable; c) portions can be forgiven; d) payment plans commonly extend for decades. Have the surgery you need to have and deal with the debt after. It's likely to take weeks if not months for all of the bills to roll in to see the total anyway. Whatever the total, you should always negotiate the portion "not covered by insurance" anyway. Some billers delete it!
posted by DarlingBri at 3:12 AM on July 9, 2018 [8 favorites]
This shouldn't be THIS hard.
No, it shouldn't be, but it definitely is. I don't know if this will be a comfort or not, but your tier system isn't necessarily causing any more confusion than "regular" insurance would. It took me three hours on the phone one day to get just a ballpark estimate of what a simple arm x-ray would cost at an in-network hospital assuming a perfectly normal 20/80% insurance coverage. Most medical professionals have absolutely no idea how much procedures/medicines cost. If you're lucky, you'll get to talk to someone in billing who has been there for a million years and has kept up on all the insurance changes.
Good luck, and your best bet might just be what DarlingBri suggests: have the surgery and deal with the debt later.
posted by cooker girl at 5:56 AM on July 9, 2018 [4 favorites]
No, it shouldn't be, but it definitely is. I don't know if this will be a comfort or not, but your tier system isn't necessarily causing any more confusion than "regular" insurance would. It took me three hours on the phone one day to get just a ballpark estimate of what a simple arm x-ray would cost at an in-network hospital assuming a perfectly normal 20/80% insurance coverage. Most medical professionals have absolutely no idea how much procedures/medicines cost. If you're lucky, you'll get to talk to someone in billing who has been there for a million years and has kept up on all the insurance changes.
Good luck, and your best bet might just be what DarlingBri suggests: have the surgery and deal with the debt later.
posted by cooker girl at 5:56 AM on July 9, 2018 [4 favorites]
I'm here to encourage you not to give up on this. By insisting on finding this out before the surgery, you're fighting a tiny fight to get away from the insanity of the "figure out if I'm ruined afterward" pricing model.
The only concrete suggestions I have are 1) see if you can get stuff in writing, in e-mail format at least, so that you can present these after-the-fact if there's "confusion", and 2) try to think of it as a kind of geeking out, so that you won't be so frustrated you end up crying.
Also, a lot of people want you to be able to do this. I hope you follow up. I may MeMail you later...
This sounds absolutely insane. Good luck.
Seriously, I'd be tempted to contact your insurance commission or the local consumer advocate reporter or something. Do it!
posted by amtho at 6:47 AM on July 9, 2018 [3 favorites]
The only concrete suggestions I have are 1) see if you can get stuff in writing, in e-mail format at least, so that you can present these after-the-fact if there's "confusion", and 2) try to think of it as a kind of geeking out, so that you won't be so frustrated you end up crying.
Also, a lot of people want you to be able to do this. I hope you follow up. I may MeMail you later...
This sounds absolutely insane. Good luck.
Seriously, I'd be tempted to contact your insurance commission or the local consumer advocate reporter or something. Do it!
posted by amtho at 6:47 AM on July 9, 2018 [3 favorites]
When my DH had to have a planned procedure I tried to get an estimate mainly because the hospital offered a 10% discount if we prepaid our balance. Calling both the hospital and insurer, I was treated like an insane person for wanting this info upfront. They hid behind ‘well it could vary depending...’ But when I asked for a total for surgery, anesthesia, hosp, etc, just the basic procedure w/o any complications, again I was spoken to like I was batty. NOBODY would give me an estimate or breakdown! Finally I get someone from the insurer to give me a figure. It took over a week of daily calls. Our final share was a fraction of the quote. Basically since I wasn’t going away they cherry picked a super high estimate. I fear you’re going to have the same fate. However, when billing time comes I suspect they’ll be careful with yours as both the hospital and insurer know how interested you are. Sorry it really should NOT be this hard! Make sure you get an itemized invoice and comb through it with a fine toothed comb for errors, preferably before you hit the cashiers office on your way out.
posted by RichardHenryYarbo at 10:41 AM on July 9, 2018 [3 favorites]
posted by RichardHenryYarbo at 10:41 AM on July 9, 2018 [3 favorites]
Response by poster: Thank you all for your responses! I'm back to report that after not giving up on this (I appreciate the rallying cries!), I found out that the surgery itself will be the $2,000 deductible, and the hospital charge is also Tier 1, so just a $250 copay. !!!!!!!!!!! (as long as everything goes as planned). That said, when the hospital told me about the $250 copay, I asked to get it in writing, and the rep flat out refused. She literally laughed. I asked her why I couldn't get a copy, and she said she couldn't tell me why, in that she had no idea. The ENT's billing person also never got the statement that Anthem was going to fax confirming the $2,000 deductible, despite follow up calls, but I did some follow up calls myself and it was documented. So in spite of having nothing in writing, I feel much more confident than when I penned this Ask. Again, many thanks (though still, what a mess).
posted by trampoliningisfun at 5:12 AM on July 13, 2018 [1 favorite]
posted by trampoliningisfun at 5:12 AM on July 13, 2018 [1 favorite]
This thread is closed to new comments.
Perhaps. Maybe. What a mess.
posted by alexei at 9:37 PM on July 8, 2018 [1 favorite]