Stuck in limbo re: reconstructive surgery for my ear (microtia).
July 15, 2021 7:35 PM Subscribe
This is a follow up to my previous question. Since then, I have switched insurance providers to Kaiser, and visited a Kaiser specialist in person to have my ear examined. I was given two options, one as an external (non-Kaiser) referral, and the other internally (with Kaiser). Things are a bit stuck in limbo (both medical and financially), and I want advice on how to proceed.
The doctor gave me those options. Note that I wear eyeglasses, so having "support" for them is vital. I also am balding, so don't have hair to cover up any defectiveness.
1) External: Plastic (will remove the half-grown, microtic ear in full, then create a prosthetic/magnetic fake ear that resembles my other, fully-grown ear).
Pros: less impact/long-term injuries stemming; no surgery other than the ear removal; fastest and apparently the most painless; also probably the most realistic-looking.
Cons: the magnet is more likely to come loose; no ear at all, so "worse" than what I have now if the magnet comes loose/falls off.
2) Internal: Medpor skin implant (will use a skin graft to form/create the other half of my ear, then sew it on)
Pros: no risk of being completely ear-less; a quick Google search of "medpor implant microtia" shows promising results
Cons: requires multiple visits, longer recovery time (~2 weeks?)
I'm honestly a bit more inclined towards the plastic surgery, only for the simpler and more effective part, but am nervous about how often/if my new ear would fall off. I'm still torn between the two options. Note: A third option was offered: medpor rib implant. Requires my rib to be pulled, long (3-6 months) recovery time, so this option will not be considered.
The medical decision is not the only factor of this where I'm in limbo. Kaiser has made it incredibly hard for me to understand the monetary component as well—what will I pay, total, out of pocket? I hate surprises, and I like knowing ahead of me what to expect I'll pay.
For the plastic surgery, this is an external referral. I've called Kaiser Member Services, and gotten mixed answers—one person said I'd only pay $400 total. Another said it'd depend on the external party's costs/co-insurance. They recommended I call the actual provider, to find out their cost. Upon doing so, I learned there'd be a consultation fee of $750 alone, then the surgery, and that they really didn't know what the total cost/Kaiser's cost would be. Even more perturbing, Kaiser's referral sheet did not seem to include the actual proper code; instead, a generic prosthetic code, so they were unable to help.
For the medpor skin implant, internal (done by a Kaiser specialist/surgeon), I also got mixed answers. The doctor/specialist I saw was unable to furnish the specific insurance code(s) for the medpor implant, so Member Services had to do some guesswork, and I got conflicting answers from this.
The bureaucratic nature of Kaiser has made it really hard for me to get a straight answer, and this is diminishing my confidence in this whole process, because I really need to know exactly what I'll be paying. I don't want any surprises or high bills that'll trigger my anxiety. My understanding is that, as a HMO, Kaiser's system should be simple enough as it's all-in-one, but this process has kind of disputed that notion.
How would you recommend I proceed and find a solution in this? Escalation paths with Kaiser? (I asked both in person and on the phone.) Any insights with plastic or medpor implants that you had in the past would be helpful (as in, plastic no way it's risky, it's too much, or medpor sucks, or whatever). I've really wanted to do this, but the way Kaiser has handled it in terms of clear answers about money has made me lose motivation to continue, so I want to get back on track and figure out a solution.
Thank you!
The doctor gave me those options. Note that I wear eyeglasses, so having "support" for them is vital. I also am balding, so don't have hair to cover up any defectiveness.
1) External: Plastic (will remove the half-grown, microtic ear in full, then create a prosthetic/magnetic fake ear that resembles my other, fully-grown ear).
Pros: less impact/long-term injuries stemming; no surgery other than the ear removal; fastest and apparently the most painless; also probably the most realistic-looking.
Cons: the magnet is more likely to come loose; no ear at all, so "worse" than what I have now if the magnet comes loose/falls off.
2) Internal: Medpor skin implant (will use a skin graft to form/create the other half of my ear, then sew it on)
Pros: no risk of being completely ear-less; a quick Google search of "medpor implant microtia" shows promising results
Cons: requires multiple visits, longer recovery time (~2 weeks?)
I'm honestly a bit more inclined towards the plastic surgery, only for the simpler and more effective part, but am nervous about how often/if my new ear would fall off. I'm still torn between the two options. Note: A third option was offered: medpor rib implant. Requires my rib to be pulled, long (3-6 months) recovery time, so this option will not be considered.
The medical decision is not the only factor of this where I'm in limbo. Kaiser has made it incredibly hard for me to understand the monetary component as well—what will I pay, total, out of pocket? I hate surprises, and I like knowing ahead of me what to expect I'll pay.
For the plastic surgery, this is an external referral. I've called Kaiser Member Services, and gotten mixed answers—one person said I'd only pay $400 total. Another said it'd depend on the external party's costs/co-insurance. They recommended I call the actual provider, to find out their cost. Upon doing so, I learned there'd be a consultation fee of $750 alone, then the surgery, and that they really didn't know what the total cost/Kaiser's cost would be. Even more perturbing, Kaiser's referral sheet did not seem to include the actual proper code; instead, a generic prosthetic code, so they were unable to help.
For the medpor skin implant, internal (done by a Kaiser specialist/surgeon), I also got mixed answers. The doctor/specialist I saw was unable to furnish the specific insurance code(s) for the medpor implant, so Member Services had to do some guesswork, and I got conflicting answers from this.
The bureaucratic nature of Kaiser has made it really hard for me to get a straight answer, and this is diminishing my confidence in this whole process, because I really need to know exactly what I'll be paying. I don't want any surprises or high bills that'll trigger my anxiety. My understanding is that, as a HMO, Kaiser's system should be simple enough as it's all-in-one, but this process has kind of disputed that notion.
How would you recommend I proceed and find a solution in this? Escalation paths with Kaiser? (I asked both in person and on the phone.) Any insights with plastic or medpor implants that you had in the past would be helpful (as in, plastic no way it's risky, it's too much, or medpor sucks, or whatever). I've really wanted to do this, but the way Kaiser has handled it in terms of clear answers about money has made me lose motivation to continue, so I want to get back on track and figure out a solution.
Thank you!
I can't answer re: how to handle Kaiser, but I can emphatically encourage you to go for the sewn on ear. My late mother had magnetic cochlear implants, and they got loose and just flat lost so many times. Every time she wore a hat, every time she just got tired of wearing the damn things (probably less of a concern when it comes to a prosthetic ear, but), every time she forgot and fell asleep with them on (so, every time she was in the hospital). If you're getting down with someone and don't take off the ear beforehand, there's a chance it could come off, etc. I would absolutely recommend the permanently attached body part. 2 weeks extra recovery time is not much in the scheme of medical issues.
posted by joycehealy at 11:09 AM on July 16, 2021 [1 favorite]
posted by joycehealy at 11:09 AM on July 16, 2021 [1 favorite]
I'm sorry you're dealing with this- I've worked with Kaiser on claims in the past (not mine! I am an HR person, I am not your HR person) with some success, and encourage you to keep trying. They are great in terms of what they cover and how their network works- so long as you're in network. But their customer service and claims departments? Not fun. Not fun at all.
1) Decide which procedure would be best for you. This is the important part. When working with an HMO like Kaiser, I would recommend going in network where possible but at the end of the day, it's your care, your body, and your decision. If cost is the deciding factor, then move to step 2 and complete step 2 for both surgeons/procedure options.
2) If your insurance is through your employer, you may have access to an advocate service or an HR person. I work with our advocates a lot, and I swear they're magic. Working in HR, one of my greatest joys is fighting insurance people for folks- and I know I'm not the only one in the field who does. If nothing else, your HR person likely has a person they work with regularly on employee issues, and they're often much more helpful than customer service.
3) If you're on your own, not comfortable taking it to HR, or anything else- it's going to be okay! I would encourage you to ask your surgeon's billing office/person/team to help. (Sometimes, there's a claim person, a billing person, etc. Other times, the hospital the surgeon is associated with handles this- but only their office will know) In order to get paid by your carrier, someone is sending in claims to Kaiser. You want to either connect with that person or submitting the claim to insurance, and they're the ones who are going to be used to Kaiser's peculiarities. If nothing else, they can provide the ICD-10 codes they generally submit for, but you'll likely have a difficult time getting anyone to commit to a specific amount prior to surgery. I see that they weren't sure what the Medpor code would be- totally understandable, since it doesn't have its own code.
4) If step 3 does not work- and it may not- a lot of the times, the insurance carrier will not know what's covered and what's not until the doctor's office submits the claim. There can be a lot of moving pieces in medical billing, and sometimes they just will not know until the procedure is over. (Extra anesthesia, extended care, out of network items, medication, etc. Kaiser has a provider guide that's useful, but- Surprise billing, bah!) The cost shared by insurance companies is just a general, frustrating estimate. I would speak to the surgeon's office about a general estimate, a payment plan, or how they handle amounts not carried by insurance. They should be able to provide this to you, along with the cost without insurance.
I hope all goes well!
posted by Torosaurus at 1:41 PM on July 16, 2021
1) Decide which procedure would be best for you. This is the important part. When working with an HMO like Kaiser, I would recommend going in network where possible but at the end of the day, it's your care, your body, and your decision. If cost is the deciding factor, then move to step 2 and complete step 2 for both surgeons/procedure options.
2) If your insurance is through your employer, you may have access to an advocate service or an HR person. I work with our advocates a lot, and I swear they're magic. Working in HR, one of my greatest joys is fighting insurance people for folks- and I know I'm not the only one in the field who does. If nothing else, your HR person likely has a person they work with regularly on employee issues, and they're often much more helpful than customer service.
3) If you're on your own, not comfortable taking it to HR, or anything else- it's going to be okay! I would encourage you to ask your surgeon's billing office/person/team to help. (Sometimes, there's a claim person, a billing person, etc. Other times, the hospital the surgeon is associated with handles this- but only their office will know) In order to get paid by your carrier, someone is sending in claims to Kaiser. You want to either connect with that person or submitting the claim to insurance, and they're the ones who are going to be used to Kaiser's peculiarities. If nothing else, they can provide the ICD-10 codes they generally submit for, but you'll likely have a difficult time getting anyone to commit to a specific amount prior to surgery. I see that they weren't sure what the Medpor code would be- totally understandable, since it doesn't have its own code.
4) If step 3 does not work- and it may not- a lot of the times, the insurance carrier will not know what's covered and what's not until the doctor's office submits the claim. There can be a lot of moving pieces in medical billing, and sometimes they just will not know until the procedure is over. (Extra anesthesia, extended care, out of network items, medication, etc. Kaiser has a provider guide that's useful, but- Surprise billing, bah!) The cost shared by insurance companies is just a general, frustrating estimate. I would speak to the surgeon's office about a general estimate, a payment plan, or how they handle amounts not carried by insurance. They should be able to provide this to you, along with the cost without insurance.
I hope all goes well!
posted by Torosaurus at 1:41 PM on July 16, 2021
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And you proceed by becoming a pain in Kaisers ass—escalate and document and don’t feel bad about it for one second. Ask the doctor again about the billing code. I don’t know is actually not okay, and Kaiser has a billing department that should be able to provide some guidance if the doctor is truly lost. (As an aside, It is so insane that in our healthcare system we are expected to agree to something and cross our fingers that it won’t put us into bankruptcy.)
Good luck!
posted by namemeansgazelle at 10:40 PM on July 15, 2021