Post op Insurance blues

[Biker60]

Well post op 3 weeks. Dr billed 6000, was paid 3000k. Implants insertion paid zero. Plan does not pay for sexual dysfunction. But pays 40k for xiaflex. Plan did pay for penis plastic surgery ? Which was the plication. Hospital Bill was 76K and still processing. My diagnosis is Peyronie’s so appeal will be the next thing to do. The plication would require the same stay and or use as the implants. So I am guessing they won’t pay for the implants. My plan does not require pre authorization. They will not accept a appeal until there is a claim. I knew this was going to happen. But also aware if it was Medicare they will get maybe 17k tops. Can’t worry about it. But men need a federal mandate as women have for breast reconstruction. The sad part is that the denial is based on one diagnostic criteria. Question any guys on FT won on appeal?

[stephen54]

Well, you can always pump that thing up to max inflation and show up at the insurance company appeals office in person....see if that gets you to the front of the line...

[Lost Sheep]

Uncharacteristically short answer from me:

Lawyer who specializes in health insurance claims.

[Biker60]

Lawyer can be used only after all appeals are used. I have a erisa health care policy. Employer is self insured. It’s the employer who pays the bills.

[Lost Sheep]

Lawyer can be used only after all appeals are used. I have a erisa health care policy. Employer is self insured. It’s the employer who pays the bills.

I think it depends on how you define, "used". I don't think any policy can prevent you from seeking advice from anywhere. I believe a lawyer can sell you advice, no matter when.

Now, I know there are contracts and policies that require mediation and such and many exclude attorney representation/participation. But simply talking privately with an adviser by all rights should be your inalienable right.

[GoodWood]

My experience with insurance billing issues (not implant but other stuff) is that it takes weeks and weeks for the dust to settle.

You are 3 weeks out? I would hold tight for several more weeks. The insurance company and providers/hospital are likely still sending bills back and forth. Don’t react yet.

[Lost Sheep]

Usually (I stress - usually) self-insured companies have claims handled by a TPA (Third Party Administrator) to determine applicability, interpret billing, adjust rates, etc. Oftern, these companies have a guide (in addition to the adjuster handling your claim) to interface between the claimant (you, the patient) and the adjuster and between the claimant and whoever is requesting payments.

Does yours have such a guide/liaison person?

[Biker60]

Well Aetna is the admin. Employer funds the plan. Aetna policy is they cover implants for PD. I fit all the criteria. But they are using the sexual dysfunction to deny . Well on the hospital portion they went form 76000 and my portion now is 41000. They did pay for the penis plastic surgery. That would be plication and plaque excisions. So they did not pay for the implants. Which seem to be around 8K . So as of now I own everyone 41k for hospital and 3k for dr. So 81k total to currently 44k. Plication was the difference. So now my appeal is then implants.

[Waynetho]

The doctors as well as my insurance administrator agree they the de facto treatment standard for PD is an inflatable implant. The doctor may have coded the claim to the insurance incorrectly. Ask him to review the claims and correct the diagnosis code to indicate that PD was the cause of the entire surgery.

[rdnkbiker]

Sorry to say I tried everything doc tried.... nothing.... got some pennies out of insurance only because they had gave us the pre authorization and a conformation # then denied it at the point of no return my surgery was tough 5hrs long owed the hospital 90k didn't include doc ,anesthesiologist ,ect..which I payed out of pocket.... so I owe a shit load but set up a payment plan with hospital implant will wear out before its payed lol I said they could come get it if the wanted lol

good luck
jim