Trying to figure out insurance options for my microtia surgery.

November 3, 2021 1:48 PM

As an update to my previous question, I met with the Kaiser doctor/surgeon, decided to stick with them instead of the original external referral for plastic surgery. However, I learned of an independent, very specific practice in Boise, Idaho, that seems world-renowned for microtia surgery. I'm unsure on what to do now.

This practice, who I had a consultation with virtually, seemed very confident that they would be able to do everything in one sitting, and I have a good feeling about them. However, the catches:

-They're out of network, out of state (not an issue for me, an issue for Kaiser)
-They accept many insurances; specifically, insurances that are PPO's, not HMO's.

I have Kaiser currently, a HMO plan. I explained my situation to them, and the very nice lady there said that she generally felt that Kaiser wouldn't be willing to do an referral, given the out-of-service-area issue and the fact that they already have a surgeon willing to do the microtia surgery on me. She seemed willing to try, however.

The problem is, while I'm glad Kaiser has a local surgeon willing to do this, and one that showed me some examples of his former work, is that it's... Kaiser. They're not known exactly for revolutionary styles of medical work, especially a niche area like my microtia. They're fine for basic issues, but microtia is definitely a bit out of the ordinary. The surgeon seems to be a general ear/nose/throat kind of surgeon, and as this is a major life decision/change, getting a specialist who is specifically specialized in this would be a big help.

So, the questions!

1) Any code words to recommend to the Boise staffers to help convince Kaiser to accept my case, despite the fact they have a surgeon willing to perform?
2) A stab in the dark... should I buy temporary, 1-2 months of PPO-based insurance (maybe Blue Cross/Blue Shield) specifically for this reason, then just cancel after the surgery is done? Or would that be misuse/even fraudulent use of insurance?
3)...or should I just stick with the Kaiser surgeon and hope for the best?

I also have open season coming up for my job/health insurance, so that's an option, but I really do want to stick with Kaiser because the ease of everything being in one place, a simplified pricing structure, and them being the cheapest is too good for me to move to another insurance provider.

Thanks! Really hoping to get this patched up soon, no pun intended!

posted by dubious_dude to Health & Fitness (7 answers total)

I’m a nurse case manager, though not your nurse case manager. I am also a former insurance company employee. I don’t believe there is any way you will be able to convince Kaiser to cover surgery in Boise when there’s a local surgeon available to you. Out of state/out of network benefits are almost universally limited to situations where the medical treatment you seek is not available locally or via an in-network provider. If your open enrollment period provides you with an option to choose a PPO that somehow provides out of state benefits, you could switch plans…but you would be stuck with that PPO until the next open enrollment period unless you quit your job. Also, it would be difficult -to-impossible to establish with certainty ahead of time whether any PPO available to you would include specialist benefits out of state. Insurance almost always provides local coverage, as each state regulates insurance independently.

I think your best bet is going to be to stick with your local Kaiser surgeon, unless you would be able to pay out of pocket for surgery in Idaho.
posted by little mouth at 2:57 PM on November 3, 2021 [3 favorites]

I agree with little mouth - the "exception" would likely be that it would be medically necessary to go to this particular surgeon, but it sounds like that argument would pass medical review.

You won't likely be able to just buy private insurance, even if you think it might cover your Idaho surgeon. The point of health insurance in the US is to not allow people to hop on and off whenever they need care because that defeats the concept of risk. If people could do that, many people would wait until they needed medical care to get insurance. You could potentially join a Marketplace individual plan, as open enrollment is coming up, but, again, I don't know that that kind of plan would cover this out of state surgeon.
posted by Pax at 4:14 PM on November 3, 2021 [1 favorite]

Response by poster: Following up with @little mouth and @pax, and anyone else reading this - thanks for clarifying.

Part of the reason I wanted to do the Idaho surgeon is because they appear to be extremely specialized, so the chances of a mistake or bad procedure should be close to zero, while Kaiser's surgeon might be a bit more "jack of all trades" in terms of surgery. Also, they would be able to do it in one sitting, vs. Kaiser's "two stages", so more convenience and less time wasted. Would those two arguments maybe help, and make it seem more "medically necessary"?

I was told by the Idaho center that they accepted, and were able to work with, various insurances; they specifically recommended Blue Cross, and they mentioned that a lot of people came from out of state, so... that's why I asked.
posted by dubious_dude at 6:28 PM on November 3, 2021

Are you eligible for FSA or HSA? You could fund the HSA account with enough for the out-of-network surgery, and save about a third by using pre-tax dollars. Some hospitals/practices make deals if you pay cash as well.
posted by typetive at 7:20 PM on November 3, 2021

Response by poster: Was told that out of pocket, I'd be paying ~$70k :\
posted by dubious_dude at 8:59 PM on November 3, 2021

Consider asking this question at Earcommunity.org, which presumably has more experience. https://earcommunity.org/microtiaatresia/

Also, is the problem Kaiser or the specific surgeon at Kaiser? I don't know your location, but Frank Garritano, MD works for Kaiser in Union City and has performed reconstructive surgery on children for a variety of problems, including microtia. He does plastic surgery for adults.

Or try contacting Brian Rubinstein, MD, a Kaiser physician in Roseville, California, who is Chief of Pediatric Otolaryngology-Head and Neck Surgery department. Ask him (or his assistant or whomever) which two Kaiser microtia surgeons for adults he would want for himself.

For sure, it's unlikely that this guy will actually name anyone, because that is not how the system works. But it might be worth a shot. If you have any questions about the one Kaiser surgeon you have met, it's okay to see if there are others at Kaiser you might feel better about.

Is the out-of-state place using more advanced technology or is the surgeon simply more experienced? Consider showing the website of the out-of-state place to that surgeon at Kaiser or other Kaiser surgeons and explain your concerns honestly.

You have wanted this surgery for a really long time. It is painful to be unable to afford the surgeon you would most like to do the operation. That said, there may well be an experienced Kaiser surgeon who can give you a good outcome if you are unhappy with the first Kaiser option. This stuff is a challenge; best of luck!
posted by Bella Donna at 4:42 AM on November 4, 2021

Response by poster: Good morning. Thanks for the helpful comment, @Bella Donna. That definitely helps—I guess it's just that I read some horror stories about specialized procedures from Kaiser, and the general sentiment online is that Kaiser is fine for basic/common issues, but the more specialized, the better it is to be somebody outside of the system. That's what is giving me pause. It's not that I doubt the surgeon I talked with at Kaiser, it's just that this is a very important procedure for me and I want to make sure I get the top care for it, while keeping within budget/parameters of Kaiser.

I have emailed the surgeon I talked with at Kaiser and explained my concerns (wanting somebody who is deeply specialized in this kind of surgery) and asked for his thoughts. If anything, he might refer me to a more experienced surgeon within Kaiser, and be able to have Kaiser cover the "out of service area" costs if needed. Let's see.

Apologies in advance for the continued threadsitting, this is kind of more of a back-and-forth situation. I will certainly check out the link Bella Donna shared and see if I can glean anything from that.
posted by dubious_dude at 7:11 AM on November 4, 2021 [2 favorites]