Insurance Preapproval and Cost Estimate

The final frontier. Deciding when, if and how.
mike123
Posts: 27
Joined: Fri Jul 10, 2020 4:01 pm

Insurance Preapproval and Cost Estimate

Postby mike123 » Fri Sep 11, 2020 12:36 am

I have a great deal of confidence in the surgeon I have chosen for my implant, but his office staff is really making me re-evaluate that choice. I plan to be implanted mid to late October and I am having his office go through the process of getting insurance preapproval and cost estimates.

They say my insurance company does not require preapproval for implant surgery, however, based on my own research, my insurance company has a list of requirements a full printed page long that must be met before they will cover the cost. I think it's rather ridiculous to not get a written preapproval. I have absolutely no plans to pay the portion of the bill that should be covered by insurance in the insurance company denies coverage after the operation.

The office has given me a verbal breakdown of my out of pocket costs, but they say that cannot give me a written cost breakdown.

Is this common in this industry or do I need to run away quickly. It seems to me that insurance preapproval and written cost breakdowns should be standard operating procedure. I don't know why I should even need to ask for it.

newbie443
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Location: Sedgwick county, Kansas USA

Re: Insurance Preapproval and Cost Estimate

Postby newbie443 » Fri Sep 11, 2020 1:21 am

Do you have other uro offices in your area you can call? I know insurance varies from state to state and company to company. Maybe from doctor to doctor. Might even ask to speek to another implant patient at your uro's office who had this done.
Injections failed. Implanted 3-21-18 AMS 700 LGX 21 + 1 RTE 100 cc reservoir Dr. Kramer. https://youtu.be/QPu9pLBM0wM

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Will show and tell and talk with others.

Hrc714
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Location: Baltimore area

Re: Insurance Preapproval and Cost Estimate

Postby Hrc714 » Fri Sep 11, 2020 6:40 am

Requireing pre approval, and being approved are seperate actions. The pre approval is a mechanism for insurance companies to aviod paying. Although you qualified for service, no pre approval, so no payment.

Not requiring pre approval does NOT mean you will be approved after surgery. I would recommend you get pre approved (required or not) and be involved in the submission with your doctors office. They dont always have access to the medical records showing that you have exhusted all other methods.
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Skier123
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Re: Insurance Preapproval and Cost Estimate

Postby Skier123 » Fri Sep 11, 2020 8:45 am

Hey Mike,

I agree with your concern. I have been burned in the past by this.

My guess is that your Drs office has dealt with your insurance co in the past and they have paid up - so they are not too concerned about getting paid.

But here's the thing - your Drs office will make you sign something that says you will pay them if your insurance doesn't. For that reason I think you need to get a pre-approval letter from your insurance company to protect yourself.

Your Dr. will make a lot of money from this surgery - and therefore wants to do it. I'd first try telling him or her that you need for his office to get a pre-approval letter or you will go elsewhere for your surgery.

In my case I actually had to call my insurance company myself to get the letter. Try calling them directly and tell them exactly what you are trying to do. If you ask nicely and get someone at the insurance company on your side, they will very likely help you get the letter.

I finally got the letter through a combination of cajoling the Drs office and talking to with my insurance company directly. I would not have gone through with the surgery without first having the per-authorization letter.
54 yr old single guy
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mike123
Posts: 27
Joined: Fri Jul 10, 2020 4:01 pm

Re: Insurance Preapproval and Cost Estimate

Postby mike123 » Fri Sep 11, 2020 12:06 pm

Thanks for all of your replies.

I live in the Orlando area so I have access to Brady in Orlando, Kata is Kissimmee and Carrion in Tampa. As I understand it, all are excellent, but I have not met with any of them yet.

I've left a message for the insurance coordinator and my current surgeon's office to follow up. I'm waiting for a call back now. I will not proceed with the surgery unless I have insurance preapproval.

I'm happy to work with the surgeon's office to help in any way I can, but at the end of the day, they are the experts and as far as I'm concerned, I'm paying them to perform this due diligence. The insurance company is going to want to see records that the doctor will need to supply.

Lost Sheep
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Joined: Mon Jul 04, 2016 11:16 pm

Re: Insurance Preapproval and Cost Estimate

Postby Lost Sheep » Fri Sep 11, 2020 6:47 pm

mike123 wrote:(edited for focus)
I'm happy to work with the surgeon's office to help in any way I can, but at the end of the day, they are the experts and as far as I'm concerned, I'm paying them to perform this due diligence.

"At the end of the day" it is up to you, no matter who you are paying, to make the due diligence to be sure THEIR due diligence has been done and done correctly.

Take written notes of every contact you have, by phone, email, text or carrier pigeon. In a separate, contemporaneous notebook, log, whatever. Thank people on the phone by name at the end of every phone call, even if they have been no help. They did give you your time. People like to be recognized and they will be left with a good feeling towards you that may be advantageous to you in the future. Have a clear idea of what you need from them. Write it down beforehand so you do not get sidetracked.

Good luck.
Lost Sheep
AMS LGX 18+3 Nov 6, 2017 Dr Shaw.
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mike123
Posts: 27
Joined: Fri Jul 10, 2020 4:01 pm

Re: Insurance Preapproval and Cost Estimate

Postby mike123 » Fri Sep 11, 2020 9:18 pm

Lost Sheep, truer words were never spoken. It's their job to get the approval. It's my job to help any way I need to and to stay on top of them until that approval comes through. It's also my job to stand my ground and walk away if they're not taking the necessary steps.

The documentation steps you have described are right on the money and is very close to the process I've used for quite a while. In my line of work, it's common for me to need the assistance of people in many other departments in order to get my job done (ie. busy people who do not report to me and who I have no direct control over). I learned a long time ago that you get much better cooperation by being pleasant. There are times when I need to be firm, but there is almost never a time to let my jerk side out.

Gt1956
Posts: 779
Joined: Fri Apr 05, 2019 2:47 pm

Re: Insurance Preapproval and Cost Estimate

Postby Gt1956 » Fri Sep 11, 2020 9:35 pm

I'd be asking them "that since there isn't an approval letter. Are you willing to provide me with any kind of collection wavier"?
In construction. In order to ensure that the materials & subs are paid. Thus not placing a lien against your property. You can ask for "lien waivers" from at least the suppliers. If the supplier has done lots of business with the contractor & always got prompt payment. They might provide that wavier.
Once you've signed the surgery paperwork. I suspect that some places will roll the dice figuring that they can squeeze you to pay a lot easier than the insurance company. Going a step further, I wouldn't be surprised if they, at a minimum, looked at your credit score.
I've been a bit surprised that this isn't common in healthcare. Wishfull thinking I'm sure. Try your best to get the approval. Safest way forward in my opinion.
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SW0110
Posts: 446
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Location: Central Kentucky

Re: Insurance Preapproval and Cost Estimate

Postby SW0110 » Sun Sep 13, 2020 9:28 pm

My last doc got not only a pre approval but a pre approval for payment authorization as well. I asked their insurance administrator specifically for it since I was concerned they were removing the titan and putting in an lgx. Warranty issues never even came up or were even mentioned.

Fyi. There is a medical code for the removal of the damaged implant and a separate code for the insertion of the new one. They should both have to be listed on the letter if it is a revision. Just fyi.
18 cm plus 1 rte titan installed March 2019. Revision March 2020 by Dr. Andrew Todd, Richmond KY. He replaced the titan with an AMS 700 LGX 18 cm cylinder plus 2 rte for 20 cm total length.

mike123
Posts: 27
Joined: Fri Jul 10, 2020 4:01 pm

Re: Insurance Preapproval and Cost Estimate

Postby mike123 » Sun Sep 13, 2020 11:44 pm

I thought a preapproval was a commitment by the insurance company that the cost of the implant/procedure would be covered and thus paid. You use the term "pre approval for payment authorization" and state that it is different from a preapproval. I am not familiar with that term. Can you please expand on what the difference is?


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