Post op Insurance blues

[jerseyhulk]

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?

I agree with you biker60. The men do need a federal mandate as women have for breast reconstruction. This is ridiculous, seems like there is a problem with every insurance company covering an implant unless you have medicare. Something needs to be done! Sick of paying for an insurance that finds ways to get out of paying for medically necessary procedures! I feel for you having to pay that much but I’m sure you may be able to come up with some type of payment agreement with them for a reduced amount. I got a damn busted implant that I’m stuck with until I can figure out how to come up with the funds or get coverage to pay for a revision. The damn insurance won’t pay and the hospital won’t budge without it being paid in full. I hope I can come up with something soon and it not take years. My fire for life is slowly becoming a shimmering glint of shit!

[Biker60]

Final bill, hospital tacked on another 11k, so 87k for hospital and 6K for Dr. Aetna says I only owe, 43K that include $500 copay for same day surgery. I have 4 appeal levels in NJ. Aetna paid 9K for the plication. Dr also did a remove excess scrotal skin which I just found out about. That was a good thing.

[FreddyFree]

Again, I can not understand why Americans put up with their healthcare. I went in got an implant and left, $0. I had a heart ablation, $0. My mother got 1 hip and 3 knee replacements, $0.

[Txagq8]

Again, I can not understand why Americans put up with their sham of healthcare. I went in got an implant and left, $0. I had a heart ablation, $0. My mother got 1 hip and 3 knee replacements, $0.

First of all. Freddy. Since your knowledge of economics is so obviously lacking, none of that stuff was free. Somebody had to pay for it. The fact that you live in some so-called country where a decision was made to tax some people to pay for the health care of others is fine. It often leads to rationing of care and bureaucratic problems but it appears your family hit the jackpot. Congratulations.

I think you ought to really rethink the way you refer to American anything. The word sham is derogatory. If things are so freakin bad here, why do folks get on airplanes and fly here to get their dicks done in Baltimore and New York among other places?

I believe I once suggested if you wanted to debate the relative merits of the health care system, we could do it privately. It is not your place to lecture Americans on whether or not it is a sham to embrace a market based or government run health care system.

[Lost Sheep]

Again, I can not understand why Americans put up with their sham of healthcare. I went in got an implant and left, $0. I had a heart ablation, $0. My mother got 1 hip and 3 knee replacements, $0.

(edited for focus)
I think you ought to really rethink the way you refer to American anything. The word sham is derogatory. If things are so freakin bad here, why do folks get on airplanes and fly here to get their dicks done in Baltimore and New York among other places?

Interesting debate subject. It may not be good to continue it here, but both questions are valid, though posed in a somewhat argumentative fashion.

FreddyFree, we put up with it because it is ours. We built it (through our Representative form of government) over the years. WE continue to (try) improve it. (Not unlike our language, which, in th previous sentence should have another "to" somewhere in it.) It is not perfect, and, I opine, neither is yours. We ration our healthcare largely by money. Other systems around the world ration by other means. But all systems ration in some way.

Txaq8, people sometimes come to this country for health care because (see my above comment about rationing) because they are restricted or delayed for healthcare they desire. Also, we have (in a preponderance of treatments) superior facilities, availability and healthcare providers. This is largely because our healthcare system is profit-driven which drives research and innovation. It is expensive (VERY expensive), but has resulted in (my opinion) most of the innovations in healthcare in this and the prior century.

Every system has advantages and disadvantages.

I note, also - just as both healthcare systems have their flaws- that both your posts have derogatory undertones. (I might be accused of my own flaws as well - but I tried to avoid them.)

The debate is a good one. The conduct of it here, maybe not so much. (In both senses that sentence may be taken)

[Biker60]

Filed first appeal. Its 2020, insurance billing takes days, not weeks. Will have decision on round one by 2/20. This is me handling the appeal. I assume hospital will resubmit the claim as well. I will have another appeal with Aetna, and if needed 3rd appeal with external review. Fourth appeal is with the employer since my policy is a erisa. Can suit Aetna at 3rd appeal. Nobody said this was going to be easy.

[Biker60]

Well read the operative report. Hospital coded the procedure as treatment for ED. Peyronies is mentioned all over my chart. Primary dx is PD. IPP associated dx was billed as ED. Now they can resubmit if they want to be paid. I never once complained about Ed. My 95 degree bent erection was my issue.