Re: - Need Your Help

[Guest guest]

Dear , Having to bother about your insurance is the last thing you need right now! I really feel for you having to go through this all in this time that is already thus difficult for you. I'm really really hoping that things work out for the best for you and that you may have your surgery done only with the best surgeon there is, the surgeon of your own choice!!! Good luck and I am really thinking of you and your family. Isabellatldund <tracylb@...> wrote: Hi ,Not sure how up to date you are with my situation, but I have scheduled my esophagectomy with Dr. Rice at TCC for March 29th. There's a long story behind the whole thing, which I won't bother you with now. My problem now is my insurance company. I was reading your story on your website and saw that you had some issues with insurance as well when it came to TCC and was wondering if you could give me any tips or anything specific that worked. My PCP has already submitted all my records, including the most recent test results and letters from Dr. Rice. The thing is, even though he is out of network for my insurance, they had already approved the initial consult, additional testing, and even the myotomy (even though at the time they approved it, we weren't sure if I was even a candidate for the myotomy - that is what the

testing was for). So now, Dr. Rice has determined I am not a candidate for the myotomy, but that I need the esophagectomy. Here's the kicker - we had already seen Dr. s in Rochester, NY, who said the same thing, back in 2005, and he is in network for us. Back then I hadn't done the research, so I didn't even know about Dr. Rice and TCC, so we just went to Dr. s and his advice was such a big step that we took some time to think about it and then did the research. So, now the insurance company is basically saying that I need to stay within network because there are doctors in network that can do it. However, the funny thing is, they aren't even saying I have to see Dr. s, they have now given me three other names, and I'm like, whatever - I have never heard of or seen any of these names anywhere....these insurance companies think we are so stupid and that we don't have a clue about what's

wrong with us. Anyway, the initial medical director that approved Dr. Rice initially is not the same one that has just denied this request. SO, we are preparing our own letter (can't wait to get that one going....), and I need to get my PCP to do more (he is out until Monday). In the meantime, after reading your story about having trouble with your insurance approving TCC, I was wondering what you did, or if there was any special info you provided that helped push it over the edge. Please let me know. I am freaking out - I have my head all set for this huge surgery, and now we only have a couple weeks to get this worked out. Anything you can suggest will be much appreciated. in NY

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[Guest guest]

,

First let me say. I’m so sorry that its come down to this

for you! At the time I had Medicaid which is Indiana’s state

insurance. That’s one of the reasons I had such a hard time. They

wanted me to go to someone I’d never heard of. In my situation I needed

something done soon, as I was at the docs office 2-3 times a week with

issues. They wanted me to wait til Dec of 2002 to just get a consult with

this doc, I needed something done then!! I had my surgery in Sept of 2002!! I

would call the customer care of your insurance, pick one person and work with

them!! Let them know that these other doctors are not specialists that are

recognized for this kind of surgery. If you have to pay more for out of network

and can afford it, I would let them know that. TCC will work with you on

payments and such, they are usually really good about that kind of thing. If

your insurance approved the myotomy, but now you aren’t a candidate, let

them know that you now have been referred to get another kind of surgery. If

you want to you can call me! I’m usually home all day!!! That might be

better! Here’s my # and if you don’t have free long distance like I

do email your # to me privately juliecwarren@...

and a time to call and I will!!! 1-317-851-8275 is my home #. And any one

on here that I’ve chatted with will tell you that I am more then willing

to talk!!!!! Hope to hear from you soon.

C Warren

Co-Founder

www.achalasia.us

From:

achalasia [mailto:achalasia ] On Behalf Of tldund

Sent: Thursday, March 08, 2007 10:04 PM

achalasia

Subject: - Need Your Help

Hi ,

Not sure how up to date you are with my situation, but I have

scheduled my esophagectomy with Dr. Rice at TCC for March 29th.

There's a long story behind the whole thing, which I won't bother

you with now. My problem now is my insurance company. I was reading

your story on your website and saw that you had some issues with

insurance as well when it came to TCC and was wondering if you could

give me any tips or anything specific that worked.

My PCP has already submitted all my records, including the most

recent test results and letters from Dr. Rice. The thing is, even

though he is out of network for my insurance, they had already

approved the initial consult, additional testing, and even the

myotomy (even though at the time they approved it, we weren't sure

if I was even a candidate for the myotomy - that is what the testing

was for). So now, Dr. Rice has determined I am not a candidate for

the myotomy, but that I need the esophagectomy. Here's the kicker -

we had already seen Dr. s in Rochester, NY, who said

the same thing, back in 2005, and he is in network for us. Back then

I hadn't done the research, so I didn't even know about Dr. Rice and

TCC, so we just went to Dr. s and his advice was such a big

step that we took some time to think about it and then did the

research. So, now the insurance company is basically saying that I

need to stay within network because there are doctors in network

that can do it. However, the funny thing is, they aren't even saying

I have to see Dr. s, they have now given me three other names,

and I'm like, whatever - I have never heard of or seen any of these

names anywhere....these insurance companies think we are so stupid

and that we don't have a clue about what's wrong with us. Anyway,

the initial medical director that approved Dr. Rice initially is not

the same one that has just denied this request. SO, we are preparing

our own letter (can't wait to get that one going....), and I need to

get my PCP to do more (he is out until Monday). In the meantime,

after reading your story about having trouble with your insurance

approving TCC, I was wondering what you did, or if there was any

special info you provided that helped push it over the edge.

Please let me know. I am freaking out - I have my head all set for

this huge surgery, and now we only have a couple weeks to get this

worked out. Anything you can suggest will be much appreciated.

in NY

[Guest guest]

, have you let Dr. Rice's office know about the problem with

insurance? Someone in his office could probably call your

insurance and work it out. I think Carolyn said that Dr. Patti's

office also took care of contacting her insurance company to work

out the approval for Cameron's surgery.

Did you get the email I sent to you off-list?

> So, now the insurance company is basically saying that I

> need to stay within network because there are doctors in

> network

> that can do it.

[Guest guest]

Isabella,

Thank you. I appreciate the support.

I was so down yesterday when I found out. And of course both my

primary doctor who is working with the insurance company, and Dr.

Rice, are both out until next week. Great.

The most frustrating part is that I was all set for this otherwise. We

have plans in place, we have a date. And now we only have two weeks to

get this worked out.

On the plus side, they picked the wrong patient to screw with. I have

some good ammunition to fire back at them, and the assertive and

educated letter is already drafting itself in my head.

in NY

Re: - Need Your Help

achalasia

> Dear ,

>

> Having to bother about your insurance is the last thing you need

> right now!

> I really feel for you having to go through this all in this time

> that is already thus difficult for you.

>

> I'm really really hoping that things work out for the best for

> you and that you may have your surgery done only with the best

> surgeon there is, the surgeon of your own choice!!!

>

> Good luck and I am really thinking of you and your family.

>

> Isabella

>

> tldund <tracylb@...> wrote:

> Hi ,

> Not sure how up to date you are with my situation, but I have

> scheduled my esophagectomy with Dr. Rice at TCC for March 29th.

> There's a long story behind the whole thing, which I won't bother

> you with now. My problem now is my insurance company. I was

> reading

> your story on your website and saw that you had some issues with

> insurance as well when it came to TCC and was wondering if you

> could

> give me any tips or anything specific that worked.

> My PCP has already submitted all my records, including the most

> recent test results and letters from Dr. Rice. The thing is, even

> though he is out of network for my insurance, they had already

> approved the initial consult, additional testing, and even the

> myotomy (even though at the time they approved it, we weren't sure

> if I was even a candidate for the myotomy - that is what the

> testing

> was for). So now, Dr. Rice has determined I am not a candidate for

> the myotomy, but that I need the esophagectomy. Here's the kicker -

>

> we had already seen Dr. s in Rochester, NY, who said

> the same thing, back in 2005, and he is in network for us. Back

> then

> I hadn't done the research, so I didn't even know about Dr. Rice

> and

> TCC, so we just went to Dr. s and his advice was such a big

> step that we took some time to think about it and then did the

> research. So, now the insurance company is basically saying that I

> need to stay within network because there are doctors in network

> that can do it. However, the funny thing is, they aren't even

> saying

> I have to see Dr. s, they have now given me three other

> names,

> and I'm like, whatever - I have never heard of or seen any of

> these

> names anywhere....these insurance companies think we are so stupid

> and that we don't have a clue about what's wrong with us. Anyway,

> the initial medical director that approved Dr. Rice initially is

> not

> the same one that has just denied this request. SO, we are

> preparing

> our own letter (can't wait to get that one going....), and I need

> to

> get my PCP to do more (he is out until Monday). In the meantime,

> after reading your story about having trouble with your insurance

> approving TCC, I was wondering what you did, or if there was any

> special info you provided that helped push it over the edge.

> Please let me know. I am freaking out - I have my head all set for

> this huge surgery, and now we only have a couple weeks to get this

> worked out. Anything you can suggest will be much appreciated.

> in NY

>

>

>

>

>

>

> ---------------------------------

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> Toolbar alerts you the instant new Mail arrives. Check it out.

>

[Guest guest]

Warren wrote:

>

> " ... The thing is, even

> though he is out of network for my insurance, they had already

> approved ... "

>

When having surgery out of network, when it has been approved, can still

leave you owing a lot more money than you would have paid in network.

The reason is the " Usual and Customary " limits to what insurance will

pay. If an out of network hospital charges $30,000 for the surgery but

the insurance typically pays something like $10,000 for it you could end

up owing the other $20,000. If you are on an 80/20 plan you will still

have to pay another $2,000 on the $10,000 they agree to, leaving you

owing a total of $22,000. Sometimes this does not happen. Sometimes you

fight it and win. Sometimes you end up paying all the rest. For more

information do a search on " Usual and Customary " .

notan

[Guest guest]

Noton,

All of the previous stuff they have approved with Dr. Rice (out of

network)has been approved at the in-network level. That is, they were

treating him as far as my share was concerned as if he was in-network,

so all we had to pay were the normal specialist co-pays. They approved

that set-up for the initial consultation, all the testing (EGD x2,

timed barium, manometry, pulmonary consult). Then they approved the

lap Heller myotomy as well, prior to me even going for the tests to

determine if I was a candidate for it.

Our insurance works based on co-pays....there are no deductibles, or

percentages. It's all set co-pays. Not sure if that makes a

difference.

in NY

Re: - Need Your Help

achalasia

> Warren wrote:

> >

> > " ... The thing is, even

> > though he is out of network for my insurance, they had already

> > approved ... "

> >

> When having surgery out of network, when it has been approved, can

> still

> leave you owing a lot more money than you would have paid in

> network.

> The reason is the " Usual and Customary " limits to what insurance

> will

> pay. If an out of network hospital charges $30,000 for the surgery

> but

> the insurance typically pays something like $10,000 for it you

> could end

> up owing the other $20,000. If you are on an 80/20 plan you will

> still

> have to pay another $2,000 on the $10,000 they agree to, leaving

> you

> owing a total of $22,000. Sometimes this does not happen.

> Sometimes you

> fight it and win. Sometimes you end up paying all the rest. For

> more

> information do a search on " Usual and Customary " .

>

> notan

>

>

[Guest guest]

Hi ,

I did call Dr. Rice's office - he is out until Monday I believe. His

secretary, , is absolutely wonderful. I have been speaking with

her very frequently on various things. She is aware of the issue with

the insurance company. She directed me to some information on the

website regarding the numbers they treat and stuff, and then sent me

over to someone else that would have more concrete numbers to give me.

I left a message and am waiting to hear back. My primary doctor is out

until Monday as well, and I have already spoken to his office.

Basically I am getting all my information together and writing a very

long, detailed letter myself, and then will speak with everyone else

monday to see what other info. I can get them to provide so we can

appeal.

I don't think I did get the other email....I know I would have

responded if I had.

Please feel free to resend it....

in NY

Re: - Need Your Help

achalasia

> , have you let Dr. Rice's office know about the problem with

> insurance? Someone in his office could probably call your

> insurance and work it out. I think Carolyn said that Dr. Patti's

> office also took care of contacting her insurance company to work

> out the approval for Cameron's surgery.

>

> Did you get the email I sent to you off-list?

>

>

>

> > So, now the insurance company is basically saying that I

> > need to stay within network because there are doctors in

> > network

> > that can do it.

>

>

[Guest guest]

That's the right attitude, ! Don't let the insurance company get the better of you! Maybe dr. Rice can be of help to you next week. I am sure that you will get you operation done by dr. Rice, I am just hoping that paper work does not have your surgery postponed. This as I know how much you must live towards the date that has been set for the surgery. I am keeping my fingers crossed for you. Isabella tracylb@... wrote: Isabella,Thank you. I appreciate the support. I was so down yesterday when I found out. And of course both my primary doctor who is working with the insurance company, and Dr. Rice, are both out until next week. Great. The most frustrating part is that I was all set for this otherwise. We have plans in place, we have a date. And now we only have two weeks to get this worked out. On the plus side, they picked the wrong patient to screw with. I have some good ammunition to fire back at them, and the assertive and educated letter is already drafting itself in my head. in NY Re: - Need Your Helpachalasia > Dear

,> > Having to bother about your insurance is the last thing you need > right now!> I really feel for you having to go through this all in this time > that is already thus difficult for you.> > I'm really really hoping that things work out for the best for > you and that you may have your surgery done only with the best > surgeon there is, the surgeon of your own choice!!!> > Good luck and I am really thinking of you and your family.> > Isabella> > tldund <tracylbstny (DOT) rr.com> wrote:> Hi ,> Not sure how up to date you are with my situation, but I have > scheduled my esophagectomy with Dr. Rice at TCC for March 29th. > There's a long story behind the whole thing, which I won't bother > you with now. My problem now is my insurance company. I was > reading >

your story on your website and saw that you had some issues with > insurance as well when it came to TCC and was wondering if you > could > give me any tips or anything specific that worked. > My PCP has already submitted all my records, including the most > recent test results and letters from Dr. Rice. The thing is, even > though he is out of network for my insurance, they had already > approved the initial consult, additional testing, and even the > myotomy (even though at the time they approved it, we weren't sure > if I was even a candidate for the myotomy - that is what the > testing > was for). So now, Dr. Rice has determined I am not a candidate for > the myotomy, but that I need the esophagectomy. Here's the kicker -> > we had already seen Dr. s in Rochester, NY, who said > the same thing, back in 2005, and he is in network for us. Back >

then > I hadn't done the research, so I didn't even know about Dr. Rice > and > TCC, so we just went to Dr. s and his advice was such a big > step that we took some time to think about it and then did the > research. So, now the insurance company is basically saying that I > need to stay within network because there are doctors in network > that can do it. However, the funny thing is, they aren't even > saying > I have to see Dr. s, they have now given me three other > names, > and I'm like, whatever - I have never heard of or seen any of > these > names anywhere....these insurance companies think we are so stupid > and that we don't have a clue about what's wrong with us. Anyway, > the initial medical director that approved Dr. Rice initially is > not > the same one that has just denied this request. SO, we are > preparing >

our own letter (can't wait to get that one going....), and I need > to > get my PCP to do more (he is out until Monday). In the meantime, > after reading your story about having trouble with your insurance > approving TCC, I was wondering what you did, or if there was any > special info you provided that helped push it over the edge. > Please let me know. I am freaking out - I have my head all set for > this huge surgery, and now we only have a couple weeks to get this > worked out. Anything you can suggest will be much appreciated. > in NY> > > > > > > ---------------------------------> Never miss an email again!> Toolbar alerts you the instant new Mail arrives. Check it out.>

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