Health insurance hand wringing
February 16, 2014 8:00 PM   Subscribe

Could a specialist on the other side of the country still be considered in-network?

An ENT I recently saw has suggested based on the pathology results they've gotten that I have a super rare tumor (likely benign) on a cranial nerve which will require a surgical procedure that usually requires the sacrifice of the nerve the controls your vocal cords. It is a "schwannoma" on my vagus nerve. From what I've read, the results of the surgery can range from outstanding!, no after-effects! to extensive neurological damage that would include drastic changes to my voice, ability to swallow and taste and effects on my facial nerve and ability to orgasm(?!) to boot. Because the type and location of the tumor is very rare, there are apparently very few surgeons in the country with significant experience operating on them and using the specific surgical methods which tend to preserve the function of the nerve.

I'm essentially a medical insurance newbie as I am thirty one years old and have never personally had a medical condition more serious than belly button lint. I am a (North Carolina) teacher and have what seems to be a kind of crappy PPO through Blue Cross Blue Shield of North Carolina.

I have been combing through Google and apparently there are doctors at Columbia and Stanford that have experience and good outcomes with these surgeries. I know Blue Cross Blue Shield is a widespread health plan, but it seems like there are subsidiaries(?), e.g. Blue Cross Blue Shield of NC. If I consulted with a Blue Cross doctor in, say, California, would that be considered in network because it's Blue Cross, or out of network because it is Blue Cross Blue Shield of some other region?

I'm wondering if a cross-country doctor could still be considered in network if my insurance provider is a huge one like Blue Cross? I hope that question makes sense.
posted by mermily to Health & Fitness (17 answers total)
The answer is a strong maybe. You should be able to log onto the website for your insurance and check to see if the doctor is in network or call Blue Cross and ask them.

There is no such thing as the Blue Cross Network. There is no such thing as the Blue Cross PPO Network. There are probably 100 Blue Cross Networks and maybe 5-10 PPO networks so it depends on which Blue Cross PPO Network you are in. It depends on if your specific Blue Cross plan has agreements with other Blue Cross networks. It depends on a lot of things, luckily this is EASILY answerable by Blue Cross themselves.
posted by magnetsphere at 8:06 PM on February 16, 2014 [2 favorites]

It really depends on your insurance. I've purposefully traveled across country for treatment but the process has been nerve wracking. It also depends heavily on if the specialists even have the availability to see you. If they don't you have to look for someone else. Good luck. Asking your insurance and the providers themselves is the only way to know for sure.
posted by AlexiaSky at 8:09 PM on February 16, 2014 [1 favorite]

Oh and I did have blue cross ppo at the time and it was considered in network.
posted by AlexiaSky at 8:12 PM on February 16, 2014 [1 favorite]

I hope someone with more expertise can explain this, but there may be way to get services from some one not in the network if the insurance agrees that no one in network has the expertise to do it. I know of people who needed specialized services that were not provided in network who were able to get a special exemption that the normally out of doctor gets authorized to provide services and patient is billed in-network rates.
posted by metahawk at 8:52 PM on February 16, 2014 [1 favorite]

I have BCBS based in Massachusetts, and live in California, and basically everything ever is "in network". I probably do not have the exact same plan as you, but there's no particular reason it wouldn't be covered.
posted by tylerkaraszewski at 9:11 PM on February 16, 2014

The Mayo Clinic. Check and see if your insurance has Mayo (Rochester, Scottsdale, Jacksonville) in-network. It is in-network for about 80% of all insurance plans and probably that percentage who have it don't realize it. Here's the Mayo Page for Neurosurgery from U.S. News Hospital rankings - #2. Not bad. Really, unless you've seen it done the Mayo way, you haven't seen medicine the way it should be practiced everywhere. There are maybe three or four institutions that I would throw in there. But, please, check with your insurance concerning Mayo Clinic.

My thoughts are with you.
posted by Gerard Sorme at 9:15 PM on February 16, 2014 [2 favorites]

You can call the 1-800 number on the back of your card and tell them, "I've been diagnosed with a super-rare tumor and the neurologists with experience operating on it are at academic hospitals in New York and California, who do I need to talk to to find out about whether that's in-network or how it would be covered?" (Insurance 1-800 phone people are actually pretty helpful for typical questions but this may have to be referred to someone in a special department because it's unusual.) It is okay to call health insurance with hypothetical questions about hypothetical diseases and treatments and they're pretty nice about it. ("I don't know what the diagnosis is yet but I want to make sure I understand all my options and costs for treatment, because obviously I'm kinda freaking out.")

A second option is that your diagnosing doctor's practice or hospital may have a patient insurance specialist whose job is literally helping you figure out what treatment options are covered by your insurance and helping you convince your insurance company to do what your doctor suggests is necessary. (Script, to doctor: "I'm confused and anxious trying to figure out what my insurance covers in terms of treatment for this, does your office have someone who can help me figure this out, or what else would you suggest?")

If you don't get an answer you like from your insurance company, you have three avenues to try: Your insurance company has an appeals process (that you and/or your doctor can pursue); there is a state ombudsman for health insurance that can help you argue with them; and your "plan administrator" (the person in charge of your plan for your employer) can argue with them (which is most helpful if your employer/insurance group is large but if you're a teacher it probably is).

You can call the state ombudsman at any time during the process, even at the beginning, and they will help explain your particular plan to you. They are very helpful; they are public servants paid by the state to help you navigate your health insurance, so they are not trying to keep costs down for insurers but trying to help you accurately understand your plan and hold the plan to its contractual obligations.

When your insurer agrees to cover the surgery at your choice of hospitals, make sure you get that in writing in some fashion.
posted by Eyebrows McGee at 9:23 PM on February 16, 2014 [4 favorites]

I never had that insurance, but with my plans, there were specialists all over the country. Also, with my plans, they were able to make exceptions for specialists and standards of care, which meant on some occasions out of network stuff was totally covered. You should talk to your insurance, but they will probably record it if there is a claim, so something to keep in mind. But they are the ones who will ultimately decide and only they can tell you if they will cover it or not. I imagine something very rare like this would fall under a special exception.
posted by AppleTurnover at 10:54 PM on February 16, 2014

Does your card have a suitcase with a PPO in it? If so, your plan is similarly in-network to any other regions BC/BS PPO (NY = Empire). If the suitcase is empty, you do not have those benefits. This advice is BC/BS specific, of course.
posted by ThePinkSuperhero at 3:43 AM on February 17, 2014 [1 favorite]

Nthing call and ask them! They will certainly have a process by which you can have the out-of-network surgeon reviewed for in-network rates.

Also, call the office of the surgeon you want to consider and explain your insurance scenario. I used an out-of-network hotshot, and he only charged me what I would have had to spend if he were in-network! The office staff will help you navigate this, they have more insider expertise than the insurance customer service people do, I promise.
posted by thinkpiece at 7:12 AM on February 17, 2014 [1 favorite]

Best answer: A friend of mine traveled from across the globe for cranial nerve surgery from Takanori Fukushima. He is located in Raleigh, NC:

edit add: Like you, she was also told that the outcome could really vary, depending on surgery (more like surgeon's skill), and she's 100% fine. Best wishes.
posted by Dashy at 9:26 AM on February 17, 2014 [1 favorite]

I have been reading about Blue Cross Blue Shield and how insurance works lately.

I agree with a lot of what has been said. Yes cross country doctors can be in-network depending on the PPO-- that's one reason they are better than HMOs. There is a very good chance your procedure will be covered wherever you get it done. I want to highlight a few different things.

First of all you need to find a specialist for you. I would start by asking the ENT for referrals. What we find ourselves and how our doctors access information about specialists differ a lot. If you trust this ENT, get him to give you some leads in the area. If you don't like this ENT keep looking. If he says he doesn't know anyone who can help you and you have to go to google to find a surgeon yourself, fire him!

I mention this because when my boyfriend had a moderately common form of brain cancer, he tried out a few of the well known clinics before he settled on the best place for him. It was maddening because people would recommend who they had seen on Dr. Oz or the big names in cancer research without knowing all that had been done in the course of coming to the decision he made about his treatment.

Your procedure is a big decision. Find out who doctors are talking about. Do involve your ENT and other doctors you trust in choosing the surgeon. Even if you have to pay for a few more consults to find out where to go next, it is much better to do that now than to settle on a place far from home. With all the research hospitals in NC someone nearby should be able to point you in the right direction. Then if you end up at Columbia you know it had to be. But maybe there's someone in NC or Atlanta who is just as skilled who everyone in that area is talking about.

Once you find that specialist/surgeon, his/her insurance / billing department will handle the insurance side for you. There's usually only a handful of specialists who can do a rare procedure. The billing people know how to tell your insurance company that in a way that the insurance company understands. You don't have to. Then BCBS NC will mark your claim as "in network."

But that all comes later. With a life changing procedure like this one the office staff does the heavy lifting for you-- even if the billing department is not nice to you or makes it easy for you to understand what's going on. It'll get taken care of.

Finally, BCBS is a name a lot of independent companies license, basically. BCBS NC should have an "ask a nurse" helpline. It's called something different in each company. I'd call them and explain your concerns about in-network/out-network and about finding ENTs and surgeons near you and so on.

My experience with the nurse lines at two different BCBS companies is that:

1) the nurses are very empathetic and knowledgeable. They seem to be nearing the ends of their careers so they have lots of experience in different fields. They genuinely want to help you on the phone.

2) they don't think much of the customer service staff and they are probably right. Customer service staff doesn't know that much.

I'm going to couch all this with the major caveat that I could be wrong on some parts or about all of what I wrote. I'm just writing about my understanding of how these things work.

I think it's going to turn out fine for you! Good luck!
posted by vincele at 11:38 AM on February 17, 2014 [1 favorite]

Response by poster: Thanks so much... I saw the ENT today and there's apparently a huge amount of gray area about what it actually is (which is apparently less definite than what I'd understood from the phone call) and what the implications of the surgery would be. He doesn't even know for sure what nerve the tumor is on, the type of tumor it is, or whether it's cancerous or not. Basically the information I am getting is that I have a tumor in my neck that may be rapidly enlarging and has to be removed ASAP, I will either recover fully and have a scar, or have seriously impaired ability to speak, eat and some other stuff if it's not on the nerve he thought in the first place. The whole thing is just an enormous shot in the dark - whether it's cancer, whether the surgery will mess up my nervous system, all of it. I thought I was going to come out with some answers in hand but came out really devastated. The guy is the head of ENT at the university hospital here. He was kind of taking umbrage when I was asking him if there were any doctors he knew of that specialized in this sort of thing because I think he considers himself to be that doctor. But how does he have almost no answers pre-surgically about what it is he is taking out, whether it's malignant, or what will happen to me? He kept saying things like, "What I'm going to do is..." that made me feel like I was just along for the ride and didn't have a say in the whole thing. Then when he was talking about all the crappy possibilities like vocal cord paralysis and having to get a loud speaker for my classroom and facial nerve palsy he was just going down the list ticking them off like it was just business as usual. It's just weird being told that everything will either be okay, or I will be physically disfigured and unable to function normally, or I might have option 1 or 2 plus a cancer which they can't identify for now.

I called Takanori Fukushima.

This has been a bad day. Anyway, thanks for your answers, when all else looks grim Metafilter still rocks.
posted by mermily at 12:36 PM on February 17, 2014

That sounds so so horrible. Doctors can be the worst. Fukushima sounds like a very good next step. Knowing what I know now after lots of bad decisions, I am sure I'd make that call too.
posted by vincele at 1:19 PM on February 17, 2014 [1 favorite]

Sorry to hear you are going through this. I would definitely get a second opinion, or third, and make it your No. 1 priority to get this dealt with quickly, but not hastily. Do all the research you can and make all the phone calls you need. I imagine worrying about your insurance will take a backseat to feeling like you are seeing a qualified doctor. Wishing you the best of luck.
posted by AppleTurnover at 2:44 PM on February 17, 2014 [1 favorite]

Hi, mermily, I'm so sorry about this. I don't know the particulars of your tumor, but you sound very uncomfortable with this doctor. That's enough for me!

Is this surgery a pressing concern? Do you have some time to get additional opinions? I would recommend getting a notebook going, write down every single concern you have, names of doctors and tests and procedures, and if you forget to ask a question or a question is not sufficiently answered to your satisfaction, you should be able to call your doctor -- your new, better doctor -- and ask as many questions as you need to. Usually you will speak with a medical assistant, and let me tell you, they are for the most part very knowledgeable and more patient than the docs.

Good good luck. Keep listening to your gut, and keep pushing to get what you need. Spend half a day on the phone if you have to, google and search, keep pushing.
posted by thinkpiece at 5:37 PM on February 17, 2014 [1 favorite]

Also, can you enlist the help of your favorite uber-organized, project-loving friend? I have learned not to take big important doc visits or even calls without some other ears listening.
posted by thinkpiece at 5:42 PM on February 17, 2014 [1 favorite]

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