Insurance question about out of pocket cost for non-network specialist
August 11, 2014 11:56 PM   Subscribe

Girlfriend needs to have fibroids removed, but needs to see a specific "out of network" surgeon. Is there any way (like some kind of a special consideration) that she can see this surgeon without paying the higher out of network cost?

A few months ago, we found out that my girlfriend has fibroids (which are a kind of non-cancerous tumor), and needs to have a surgery to get them removed.

She just moved to another state to start a new job, and that job comes with an insurance package. She needs to have a surgery for fibroids, however, she needs to use a particular surgeon in another state, and that surgeon is not in network for her. Since it's not in network the out of pocket maximum goes from 5,000 dollars, to 10,000 dollars.

She can't afford the difference in price, but she really needs to get this surgery, as the fibroids have grown, and grown, and now they are causing pain around the clock and distending her lower abdomen quite a bit, so she needs to have this surgery (laproscopic myomectomy) to remove the fibroids.

She's on her own, and I think she feels isolated from me, and her family, in addition to feeling like she's at the end of her rope/out of options. I want to help her, but I don't really know much about the particulars of insurance, so I'm looking for any help, or advice I can get.
posted by hanzoschmanzo to Health & Fitness (6 answers total) 1 user marked this as a favorite
You need to call your insurance company and ask. My insurance company had exception for highly-skilled specialists that got me out of paying a lab bill. Basically, if there was a concern an in-network choice would be poor quality or was really out of the way, they would pay for out-of-network. You need to ask them what the exceptions are that allow out-of-network procedures. I'd ask about the criteria and how it's approved, but not explain the situation until you know what you are going to argue for.
posted by peachpie at 12:12 AM on August 12, 2014 [1 favorite]

Why does she need to see that specific surgeon? Myomectomies are fairly common, though it is more difficult to find gynaecologists who can and will perform the procedure laproscopically. If the problem is that she can't find a doctor & hospital in her network who can perform a laproscopic myomectomy, she might have a shot at convincing her insurance company to make an exception. An argument that may help her, if this is the issue, is that a little outpatient procedure could be so much cheaper for the insurance company than a big old surgery with a hospital stay. (YMMV, it might not actually be cheaper for them; medical billing is weird.)

I wonder if this might go beyond a simple insurance issue, though. Many doctors and hospitals have recently stopped performing laproscopic uterine surgeries altogether. Has your gf's Gyn explained the risks of laparoscopic power morcellation? Apparently, if there are previously undetected cancerous cells, there is a chance that they could spread internally when the fibroids are broken into bits small enough to be removed through the tiny incision.

(I also wondered if your gf's insurance company had stopped covering the procedure altogether, but upon googling, only one insurance company has so far, and the ban doesn't begin until next month.)
posted by lesli212 at 1:01 AM on August 12, 2014 [3 favorites]

Ask if the insurance will do a single case agreement, and ask if the doctor's office will accept it. They might if there's no one in their local network who would do the surgery, though you may have to prove that other specific methods have failed.
posted by ThePinkSuperhero at 3:26 AM on August 12, 2014 [1 favorite]

She needs to have a surgery for fibroids, however, she needs to use a particular surgeon in another state

Want and need are two different things. Fibroids are routine; why does she need to see this particular surgeon?
posted by DarlingBri at 5:28 AM on August 12, 2014

I know it may seem a bit harsh and blunt of posters here to be all, "Why does she need to see this particular surgeon?" but it's exactly what the insurance company is going to want to know, so it would be best if she has a very good answer.
posted by mskyle at 6:12 AM on August 12, 2014 [1 favorite]

Many insurance companies will process overrides for this sort of thing if she can get a doctor who is in-network to certify that none of the doctors in the insurance network are able to perform the procedure, and that only this one specific doctor can do it, and that this specific procedure is the only way to cure the condition. But the criteria are very stringent, so be prepared to be fighting this for a while, through multiple levels of the insurance company bureaucracy.
posted by decathecting at 3:30 PM on August 12, 2014 [1 favorite]

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