RE: Need a little insurance info and cost info re TCI

[Guest guest]

TCI insurance Kathleen's response:

I started to see Dr. Milhorat in 1998, he was in Brooklyn at that time and

insisted that the patient have insurance coverage approval before the first

appointment. That sure did make me go after my insurance company.

I've had 3 different insurance companies, and my husband has worked for 2

different employers since that time.

I was first decompressed in 1990 and was told I was cured, I had migraines

that lasted 24/7 for 8 years, I fell in 1997 landing on the back of my head

and that is when my " migraine " became hell. All kinds of symptoms became out

of control. I pleaded with my neurologists and neurosurgeons for help and

was told the same story. I asked for a second opinion and I was told to see

Dr. Milhorat in NY, but I would waste his time.

At least I had my referral, I had my first surgery and it had failed. I had

to fight three appeals but my primary was on my side. She wrote letters and

appealed right along my side. I was finally appealed the last appeal. I had

a second decompression, craniocervical fusion, then a shunt revision in

December.

My husband changed employers that month, and my shunt failed in Jan. The

state of Maine says that we have to be covered for a previous condition for

up to three months, thus I was covered under the new companies plan which

was the same as the old company.

We had to fight when another surgery came up, but the company my husband

worked for and is still working for is self insured. Meaning they put so

much money aside for health insurance each year and Aetna pays the insurance

bills. We have had to continue to battle, but have finally battled our last

battle. They have proved that I need to go to TCI by paying previous

surgeries.

In other words, they have set precedence by covering several surgeries for

me.

TCI does take insurance, if your insurance pays 30% out of network, and

TCI's charge is $100, your charge would be $70. Most insurance companies

will have out of pocket maximum fees. Talk to your Human Resource Department

for assistance, they will be of great help.

There are links on line as well, Google health insurance appeal and you will

come up with several links.

If I can help in any way, just let me know.

Kathleen

Hello. I understand that the TCI neurosurgeons do not take insurance, but

that the facility and the hospital do............so, where does that leave

you after surgery? You are expected to pay out of pocket for the NSG

charges?% of what isn't covered. If your insurance pays 30% ??? -and what

are those charges?

Also, can anyone explain to me how I go about talking to my insurance

company, even though I have out of network benefits with a 30% coinsurance,

to allow me to go to TCI and cover all of it....even though I am expected to

pay the coinsurance, which would still be a pretty large sum.... b/c of

having two rare conditions, and no one in my area is knowledgeable in

regards to these two conditions existing together.

I saw a Sleep Doc today, and he was irate at the treatment that I have been

receiving around town, that no one is helping me. He said that he cannot

begin to understand why a neurosurgeon would not be willing to say that a

condition is out of their area of expertise. I asked him if he ever met a

neurosurgeon. He said that with two rare conditions, that insurance should

allow me to see an expert, w/o me having to pay the 30% coinsurance. Is

this correct?

Sorry if I am not getting my point across. I have no clue how to address

this situation.

Thanks,

Pam

------------------------------------

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Lots Of Information That May Be Helpful

[Guest guest]

Dear Pam,

 

My husband had surgeries thru TCI. 

 

What you have to keep in mind is that it's 70% of usual and customary fees set

by your insurance company.  Not 70% of what TCI charges. 

 

I have learned a lot in the past few years from personal experience and I am

also in Human Resources.

 

What type of surgery are you having? You should ask TCI for the procedure codes

for the surgery then call your insurance company and ask them to provide you

with the " usual and customary fee " for those codes.  Then email your contact at

TCI to see if they are in the ball park - they wouldn't give me their charges

for the codes.

 

However, it doesn't end there. The surgeries have multiple procedure codes. 

However, some insurance companies state that with a multiple code surgery, they

will only pay the usual and customary on the main procedure code, then 50% of

usual and customary on the rest.  I found this out after my husbands two

surgeries - TCI said that they never heard of this and when I thought that i

only owed around $10,000 from my due diligence, I wound up owing $144,000.  

In addition, if you have two neurosurgeons operating on you, make sure they are

labeled co-surgeons, not asst. surgeons - there is a big difference in the fee

that insurance companies will pay.

 

If you are having decompression or tethered cord surgery, I may have the

procedure codes from 2 years ago that was given to me - let me know and i will

try to locate them.

 

I wish you the best!

Subject: Need a little insurance info and cost

info re TCI

To:

Date: Monday, March 8, 2010, 3:37 PM

 

Hello. I understand that the TCI neurosurgeons do not take insurance, but that

the facility and the hospital do.......... ..so, where does that leave you after

surgery? You are expected to pay out of pocket for the NSG charges???? -and what

are those charges?

Also, can anyone explain to me how I go about talking to my insurance company,

even though I have out of network benefits with a 30% coinsurance, to allow me

to go to TCI and cover all of it....even though I am expected to pay the

coinsurance, which would still be a pretty large sum.... b/c of having two rare

conditions, and no one in my area is knowledgeable in regards to these two

conditions existing together.

I saw a Sleep Doc today, and he was irate at the treatment that I have been

receiving around town, that no one is helping me. He said that he cannot begin

to understand why a neurosurgeon would not be willing to say that a condition is

out of their area of expertise. I asked him if he ever met a neurosurgeon. He

said that with two rare conditions, that insurance should allow me to see an

expert, w/o me having to pay the 30% coinsurance. Is this correct?

Sorry if I am not getting my point across. I have no clue how to address this

situation.

Thanks,

Pam

[Guest guest]

Hi All,

Keep in mind this is two year old information. The procedure codes may have

changed by now, as well as fees. It is still best to check with your HR

department and TCI.

There is still quite a bit of great information in the below post.

Kathleen

 

My husband had surgeries thru TCI. 

 

What you have to keep in mind is that it's 70% of usual and customary fees

set by your insurance company.  Not 70% of what TCI charges. 

 

I have learned a lot in the past few years from personal experience and I am

also in Human Resources.

 

What type of surgery are you having? You should ask TCI for the procedure

codes for the surgery then call your insurance company and ask them to

provide you with the " usual and customary fee " for those codes.  Then email

your contact at TCI to see if they are in the ball park - they wouldn't give

me their charges for the codes.

 

However, it doesn't end there. The surgeries have multiple procedure codes. 

However, some insurance companies state that with a multiple code surgery,

they will only pay the usual and customary on the main procedure code, then

50% of usual and customary on the rest.  I found this out after my husbands

two surgeries - TCI said that they never heard of this and when I thought

that i only owed around $10,000 from my due diligence, I wound up owing

$144,000.   In addition, if you have two neurosurgeons operating on you,

make sure they are labeled co-surgeons, not asst. surgeons - there is a big

difference in the fee that insurance companies will pay.

 

If you are having decompression or tethered cord surgery, I may have the

procedure codes from 2 years ago that was given to me - let me know and i

will try to locate them.

 

I wish you the best!

Subject: Need a little insurance info and

cost info re TCI

To:

Date: Monday, March 8, 2010, 3:37 PM

 

Hello. I understand that the TCI neurosurgeons do not take insurance, but

that the facility and the hospital do.......... ..so, where does that leave

you after surgery? You are expected to pay out of pocket for the NSG

charges???? -and what are those charges?

Also, can anyone explain to me how I go about talking to my insurance

company, even though I have out of network benefits with a 30% coinsurance,

to allow me to go to TCI and cover all of it....even though I am expected to

pay the coinsurance, which would still be a pretty large sum.... b/c of

having two rare conditions, and no one in my area is knowledgeable in

regards to these two conditions existing together.

I saw a Sleep Doc today, and he was irate at the treatment that I have been

receiving around town, that no one is helping me. He said that he cannot

begin to understand why a neurosurgeon would not be willing to say that a

condition is out of their area of expertise. I asked him if he ever met a

neurosurgeon. He said that with two rare conditions, that insurance should

allow me to see an expert, w/o me having to pay the 30% coinsurance. Is this

correct?

Sorry if I am not getting my point across. I have no clue how to address

this situation.

Thanks,

Pam