Insurance Pre-approval
On Friday, July 17th I met with Dr. Byrd in her office for the pre-certification appointment, needed in order to submit the paperwork to insurance for pre-approval. The following week her office submitted all of the necessary paperwork and documentation, including information about lipedema and benefits of surgery.
The request was for 6 surgeries (units). 3 lower extremity, 2 trunk, 1 upper extremity.
I called to follow up on August 5th and was told that all of my surgeries had been approved. I requested in-for-out coverage so I’d only have to pay based on my in-network benefits. This is important to know, because without this pre-approval my cost would have been tens of thousands of dollars more. The rep conferenced in a nurse who works in the in-for-out department and she filed the request. That was approved as well.
When I got the approval notification in the mail, I saw that it showed 3 units had been approved, one for each extremity instead of the six which had been requested.
I called Dr. Byrd’s office and Kia (her insurance guru) resubmitted the paperwork.
I got another pre approval this time for 5 units- 2 lower, 1 trunk, and 2 upper. Not sure where that came from, but I called my insurance company told them it was wrong, they looked at the original request, saw the error and fixed it. Momentarily stressful, but ended up being no big deal.
The biggest issue was that I had to request in-for-out again because it was a whole new pre-approval.
It was annoying to have to stay on top of all of this, but in the end, it was worth it. And it was ultimately my responsibility. Had I not requested the in-for-out coverage, the surgeries would have cost me more than $35,000.00 out of pocket instead of $2,698.00. HUGE difference.
Our in network deductible was $1,900 vs out of network, $7,600.
Our max out of pocket was $6,650 in-network, vs $19,200 for out of network, and co-insurance of 20% vs 50%.
On August 8th I booked my first surgery for August 20th.
Everything happened much faster than I anticipated. I had originally thought I was just getting my ducks in a row and that I’d have the surgeries in 2021, but my insurance company doesn’t offer extensions so I would have had to start the whole process over again, in January.
This meant that I needed to complete all six surgeries before the end of 2020 or else I’d have to go through the pre-approval process again, and my deductible would refresh. Somehow everything worked out in my favor. I feel extremely fortunate.
Filing Insurance
Tips:
- Get pre-approval.
- Understand that you will probably need to prove that you’ve tried some conservative therapies first.
- Request “in-for-out” coverage if you’re pre-paying. (if your surgeon is out of network)
- Or request a single case agreement so you don’t have to pay out of pocket.
- Know your deductible.
- Know your max out of pocket.
- Stay on top of your insurance company. Don’t give up. Be patient.
Even though I want to deliver all of this in chronological order, I think it’s important to keep this information together.
Like I said, I got all of my surgeries pre-approved. I talked to three different reps and asked them to verify that I wouldn’t have to pay more than my in-network max out of pocket. All three said yes.
I filed my first claim around August 25th using a mobile fax app. I called to check on the claim after two weeks and was told it had been denied because the dates were cut off on the document I faxed—my fault.
The rep offered to key and submit the claims for me, and said she would do the same for my future surgeries. I accepted her offer.
While waiting for the first reimbursement I had my second surgery and third surgeries. I sent her those claims as well.
I called a few times to follow up but no one could find the claims. When I finally got to speak to the original rep, she told me that they had all been denied for various reasons. I had already paid almost $40k out of pocket, with my fourth surgery booked for the following week.
She assured me that everything was okay, that I would be reimbursed, she just needed to resubmit the claims. She also told me that I would get daily email updates from Anthem to tell me the status of my claims. A week went by and I didn’t receive anything.
I called back and lucked into talking to a rep who had been with Anthem for 12 years and knew exactly what to do. She said it would take her a day or two to investigate and that she would call me as soon as she knew what was going on. At this point my fourth surgery was done and I was ready to file that claim too. She told me to send it to her and that she would take over my case.
It took her about a week to figure out what was going on, but she called to update me and sent me emails to let me know she was still working on it.
As it turned out, the first rep had miss-keyed the first three claims and then resubmitted the second two before they were actually denied so everything was sitting in claim limbo. The new rep informed her supervisor and she was able to escalate everything.
As of January 5, 2020 I have received one check in the amount of $7,880.00 for my third surgery (10/15) which was the first to be approved properly (the first two are still in limbo due to the first rep’s errors, but are being processed). The total bill was $9,850.00, meaning I paid $1,970.00 for that surgery. (I still hadn’t met my deductible prior to that procedure so a portion of my responsibility is to meet that amount.)
I can see on the Anthem website that all of my claims have been approved and I am responsible for $2,698.00 of the $57,000. Which means they will reimburse me $54,302.00 when all is said and done.
GO TO NEXT POST IN THIS SERIES
I hope you find the information in this series of posts helpful. If you have any questions, please don’t hesitate to email me.
<3 Andrea
Andrea Matthes
Body Image and Healthy Lifestyle Coach
Founder of I’mperfect Life, LLC.
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All content found this website, including: text and images, were created for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you read in this document.
If you think you may have a medical emergency, call your doctor, go to the emergency department, or call 911 immediately. Andrea Matthes does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned in this document. Reliance on any information provided is solely at your own risk.
Dr. Byrd/Lipedema Surgery Center https://lipedemaliposuctioncenter.com/
11050 Crabapple Road
Building B
Roswell, Georgia 30075
Telephone: 770.587.1711
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