Guest guest Posted July 19, 2000 Report Share Posted July 19, 2000 wrote: > > I am a newbie and maybe I am just overlooking the information in all > I have read. > > At what point does the does the insurance company get contacted for > prior approval. > > I have e-mailed my infomation form in. I have my letter, family > support letter, almost all my contacts and just wait for my local Dr. > letter and the testing to mail in my packet. I am assuming he has to > receive all this before the insurance company is going to get any > requests am I right? > > Thanks When you submit the online patient form, that form is submitted to your insurance company, usually the next day. Kind regards, Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2000 Report Share Posted July 19, 2000 Thanks hon! That question just kept me going trying to put it in place hugs > > > > I am a newbie and maybe I am just overlooking the information in all > > I have read. > > > > At what point does the does the insurance company get contacted for > > prior approval. > > > > I have e-mailed my infomation form in. I have my letter, family > > support letter, almost all my contacts and just wait for my local Dr. > > letter and the testing to mail in my packet. I am assuming he has to > > receive all this before the insurance company is going to get any > > requests am I right? > > > > Thanks > > When you submit the online patient form, that form is submitted to your > insurance company, usually the next day. > > Kind regards, > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 25, 2001 Report Share Posted July 25, 2001 Hi, I have Empire Healthchoice (AKA Bluechoice) Prestige BC/BS. My file was submitted for pre-approval about a week ago. I haven't heard anything yet, but will post as soon as I do. I am having Dr. Inabnet (in the same team as Dr. Gagner) do my surgery. Different surgeons take different insurances, and I can't help with the specifics, but can relay my experience. Maggie > I apologize, I know this subject has been covered over and over, maybe I > couldn't find the answer to my question because of the wealth of information in > the archives. I'd really appreciate some guidance on this. > > I called Dr. Gagner's office, and they told me that " Dr. Gagner is no longer > accepting any insurance. " I understand the insurance person there is Darryl, > who wasn't in, but I will try again today. > > Does anyone understand what this means? I'm an NYC resident, and I have Empire > BC/BS. > > I've been living overseas for a few years so my mind is drawing a total blank on > how insurance works in the States. I had to empty out my brain so I could learn > about national health insurance instead. Believe me, by now even BC/BS is > beginning to look good. > > I'm pretty sure this doesn't automatically mean " no insurance, " but I'm confused > as to what the next step is supposed to be. I'm guessing that in terms of Dr. > Gagner's office, I will have to commit to paying the entire fee whether or not I > get it back from my insurance company, which is fine. Not fine, of course, but > I'm prepared for that eventuality, I want my life back. But I'm sure there's > still something I'm supposed to do before blithely signing away my savings > account... > > I just don't know where to go from here. Am I supposed to get pre-approval from > BC/BS (something I understand isn't possible with some states' BC/BS, but I > don't know about New York)? On the miracle chance that they'll cover it - can > they squirm their way out of it through the fine print if I didn't follow some > kind of pre-authorization process? Is Dr. Gagner's office involved in this > process prior to the surgery, or only after I pay the bill, or never? > > And is there something I need to know about coverage of the hospital fees, or > does that all go in one package? If the procedure isn't approved, and I > self-pay - what happens if there are complications requiring additional > hospitalization? Does BC/BS review that under a different category, or do they > just flat-out turn it down because the complications resulted from a procedure > that wasn't covered? > > Does anyone have any idea where I can find out about any of this? > > Needless to say, the BC/BS websites are useless for these kinds of questions, as > is the policy itself - it's so full of double-speak it's as if it was written in > another language. > > Thanks and sorry again for asking the same questions that have been asked so > often. I really need some hand-holding through this, and I am immensely grateful > for any guidance. > > Aviva Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 25, 2001 Report Share Posted July 25, 2001 In a message dated 7/25/01 1:51:06 PM, duodenalswitch writes: << I called Dr. Gagner's office, and they told me that " Dr. Gagner is no longer accepting any insurance. " I understand the insurance person there is Darryl, who wasn't in, but I will try again today. Does anyone understand what this means? I'm an NYC resident, and I have Empire BC/BS. >> Oh, wow -- this could very well be true. I know that he stopped taking Oxford (Freedom) -- my insurance carrier - in May, 2001. I got extremely nervous because I had my surgery on Jan. 25 of this year! I was able to qualify for 'transitional care' since I have already had my surgery for the rest of the year... but if one hasn't had surgery, I think it would be self-pay if one choose Gagner. I do believe the other associates (Herron, Pomp, Ibarnet) all take insurances. Dr. Quinn is supposed to join in Sept.. but she won't get insurance clearance, etc for quite some time after that (at least this is what Daryl informed me - not to wait for her because she isn't even registered with the insurance companies, etc. or even a surgeon with the team yet). all the best, lap ds with gallbladder removal january 25, 2001 six months post-op and still feelin' fabu! pre-op: 307 lbs/bmi 45 (5'9 1/2 " ) now: 234 (hangin' there for awhile!) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 25, 2001 Report Share Posted July 25, 2001 I had a consult with Dr Gagner last week, and was told they would put in for insurance approval with BC of Illinois that I have. Sheryl Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2001 Report Share Posted July 26, 2001 I believe that (correct me if I am wrong) even if your surgeon doesn't take your insurance, you can still be approved as out-of-network. I don't think this means Dr. Gagner won't accept any payments from insurance, only that he won't pay them a membership fee for the privelege of being in-network. I have Empire Healthchoice BC/BS (Prestige plan) and am using Dr. Inabnet who is out-of-network, but I was told it shouldn't be a problem. I will post as soon as I know If it was approved. My surgery date is August 24th, so I should have approval soon. Hopefully... Maggie > > In a message dated 7/25/01 1:51:06 PM, duodenalswitch@y... writes: > > << I called Dr. Gagner's office, and they told me that " Dr. Gagner is no > longer > accepting any insurance. " I understand the insurance person there is Darryl, > who wasn't in, but I will try again today. > > Does anyone understand what this means? I'm an NYC resident, and I have Empire > BC/BS. > >> > > Oh, wow -- this could very well be true. I know that he stopped taking > Oxford (Freedom) -- my insurance carrier - in May, 2001. I got extremely > nervous because I had my surgery on Jan. 25 of this year! I was able to > qualify for 'transitional care' since I have already had my surgery for the > rest of the year... but if one hasn't had surgery, I think it would be > self-pay if one choose Gagner. > > I do believe the other associates (Herron, Pomp, Ibarnet) all take > insurances. Dr. Quinn is supposed to join in Sept.. but she won't get > insurance clearance, etc for quite some time after that (at least this is > what Daryl informed me - not to wait for her because she isn't even > registered with the insurance companies, etc. or even a surgeon with the team > yet). > > all the best, > > lap ds with gallbladder removal > january 25, 2001 > > six months post-op and still feelin' fabu! > > pre-op: 307 lbs/bmi 45 (5'9 1/2 " ) > now: 234 (hangin' there for awhile!) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2001 Report Share Posted July 26, 2001 In a message dated 7/26/01 6:30:13 PM, duodenalswitch writes: << I believe that (correct me if I am wrong) even if your surgeon doesn't take your insurance, you can still be approved as out-of-network. I don't think this means Dr. Gagner won't accept any payments from insurance, only that he won't pay them a membership fee for the privelege of being in-network. >> Hi, Maggie: Yes, you are right - tHis would be true if one has a PPO that offers 'out of network services'. However, I would prefer to pay in network since I obtained the surgery in network earlier this year. For anyone who experiences this, it's good to know that there is such a thing (at least at Oxford, although I would think other insurance companies would offer similar options) as 'transitional care'. My situation is different in that I did get insurance approval and had the surgery while Gagner was in network but he subsequently dropped my insurance. For those who haven't gotten approvals yet, it is still possible to use Dr. Gagner as an out of network provider in many cases. I guess I would clarify this with one's insurance company to get the nitty gritty details. So, yes--- I think that for those whose insurance doesn't take Dr. Gagner and they have a PPO/out of network option, they could still get surgery approval, etc. and pay as an 'out of network' participant. This means that they wouldn't be covered as totally as in network but a certain percentage would be paid by the insurance company, rather than totally 'out of pocket/self pay'. all the best, lap ds with gallbladder removal January 25, 2001 six months postop and still feelin' fabu! pre-op: 307 lbs/bmi 45 (5' 9 1/2 " ) now: 233 (another lb bites the dust, man!) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2001 Report Share Posted July 26, 2001 In a message dated 7/26/01 6:30:13 PM, duodenalswitch writes: << I believe that (correct me if I am wrong) even if your surgeon doesn't take your insurance, you can still be approved as out-of-network. I don't think this means Dr. Gagner won't accept any payments from insurance, only that he won't pay them a membership fee for the privelege of being in-network. >> Hi, Maggie: Yes, you are right - tHis would be true if one has a PPO that offers 'out of network services'. However, I would prefer to pay in network since I obtained the surgery in network earlier this year. For anyone who experiences this, it's good to know that there is such a thing (at least at Oxford, although I would think other insurance companies would offer similar options) as 'transitional care'. My situation is different in that I did get insurance approval and had the surgery while Gagner was in network but he subsequently dropped my insurance. For those who haven't gotten approvals yet, it is still possible to use Dr. Gagner as an out of network provider in many cases. I guess I would clarify this with one's insurance company to get the nitty gritty details. So, yes--- I think that for those whose insurance doesn't take Dr. Gagner and they have a PPO/out of network option, they could still get surgery approval, etc. and pay as an 'out of network' participant. This means that they wouldn't be covered as totally as in network but a certain percentage would be paid by the insurance company, rather than totally 'out of pocket/self pay'. all the best, lap ds with gallbladder removal January 25, 2001 six months postop and still feelin' fabu! pre-op: 307 lbs/bmi 45 (5' 9 1/2 " ) now: 233 (another lb bites the dust, man!) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 24, 2003 Report Share Posted July 24, 2003 , Originally, Cigna told me NO WAY they do not cover the boots or the bar. But recently I have been putting up a big stink about everything and, apparently, now they will pay for the boots and bar if your doctors sends them a letter stating their " medical necessity " Re: insurance question Hi, Does anyone know if CIGNA covers the Markell boots? Thanks Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 24, 2003 Report Share Posted July 24, 2003 , Originally, Cigna told me NO WAY they do not cover the boots or the bar. But recently I have been putting up a big stink about everything and, apparently, now they will pay for the boots and bar if your doctors sends them a letter stating their " medical necessity " Re: insurance question Hi, Does anyone know if CIGNA covers the Markell boots? Thanks Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 21, 2004 Report Share Posted August 21, 2004 My claim took 3 months to be accepted, and it was denied the first time. My Orthodontist played a big part in the approval process. He worked my surgeon on the appeals as well. I also had my braces put on before I even thought about surgery. I didn't want to go through with it unless I absolutely had to. I had my braces on for a full year before we decided there was nothing non-surgical that could be done (*that I would be satisfied with*) and so started the insurance process. Some things to note about the way I did it: I would have been ready for, and probably scheduled for surgery way back in April had I done the insurance thing sooner, instead of taking so long to decide to go through with it. I don't mind wearing the braces a few months longer though, and I don't regret doing it the way I did. I don't think I would have started the insurance process before getting the braces on regardless. Even without surgery, for me, the braces were needed in a bad bad way. Hope this helps! ~Jen > I will need orthognathic surgery to achieve my best bite, but I'm > afraid that I will have to wait and wait for my insurance to accept > my claim - if they do at all (I've heard some horror stories about > insurance). Anyway, does anyone here have any insight on this > subject? Also, I'm wondering if the orthodontist has anything to do > with the insurance issue or is everything totally handled by the oral > surgeon? Is it possible to get the braces on before the surgery has > been accepted by the insurance? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 21, 2004 Report Share Posted August 21, 2004 My claim took 3 months to be accepted, and it was denied the first time. My Orthodontist played a big part in the approval process. He worked my surgeon on the appeals as well. I also had my braces put on before I even thought about surgery. I didn't want to go through with it unless I absolutely had to. I had my braces on for a full year before we decided there was nothing non-surgical that could be done (*that I would be satisfied with*) and so started the insurance process. Some things to note about the way I did it: I would have been ready for, and probably scheduled for surgery way back in April had I done the insurance thing sooner, instead of taking so long to decide to go through with it. I don't mind wearing the braces a few months longer though, and I don't regret doing it the way I did. I don't think I would have started the insurance process before getting the braces on regardless. Even without surgery, for me, the braces were needed in a bad bad way. Hope this helps! ~Jen > I will need orthognathic surgery to achieve my best bite, but I'm > afraid that I will have to wait and wait for my insurance to accept > my claim - if they do at all (I've heard some horror stories about > insurance). Anyway, does anyone here have any insight on this > subject? Also, I'm wondering if the orthodontist has anything to do > with the insurance issue or is everything totally handled by the oral > surgeon? Is it possible to get the braces on before the surgery has > been accepted by the insurance? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 21, 2004 Report Share Posted August 21, 2004 Yes, for me it was possible to start the orthodontia, because my mouth needed a lot of help. You do reach a point, however, at which you need to decide whether or not you will have the surgery, because the corrections are different, for surgery or not. You can have significant, and perhaps functional, correction without surgery, sometimes, depending on your situation. I could have, maybe, but the correction is much more stable, I was told, with the surgery than it would have been without. I would have undertaken the braces, even if the surgery had been denied. (Today, two-plus years post-op and approaching two years after the debanding, I still wear the acryllic retainers, 14 hours a day or more, and plan to continue that for the rest of my life.) My ortho told me he thought it would be covered, but sent me to an early appointment with the surgeon he recommended. The surgeon filed an early pre-certification application, which was approved. That expired, but was renewed when he refiled, closer to the actual time. I am not saying that this experience will be yours. I was most grateful that it was mine. Cammie > I will need orthognathic surgery to achieve my best bite, but I'm > afraid that I will have to wait and wait for my insurance to accept > my claim - if they do at all (I've heard some horror stories about > insurance). Anyway, does anyone here have any insight on this > subject? Also, I'm wondering if the orthodontist has anything to do > with the insurance issue or is everything totally handled by the oral > surgeon? Is it possible to get the braces on before the surgery has > been accepted by the insurance? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 21, 2004 Report Share Posted August 21, 2004 Yes, for me it was possible to start the orthodontia, because my mouth needed a lot of help. You do reach a point, however, at which you need to decide whether or not you will have the surgery, because the corrections are different, for surgery or not. You can have significant, and perhaps functional, correction without surgery, sometimes, depending on your situation. I could have, maybe, but the correction is much more stable, I was told, with the surgery than it would have been without. I would have undertaken the braces, even if the surgery had been denied. (Today, two-plus years post-op and approaching two years after the debanding, I still wear the acryllic retainers, 14 hours a day or more, and plan to continue that for the rest of my life.) My ortho told me he thought it would be covered, but sent me to an early appointment with the surgeon he recommended. The surgeon filed an early pre-certification application, which was approved. That expired, but was renewed when he refiled, closer to the actual time. I am not saying that this experience will be yours. I was most grateful that it was mine. Cammie > I will need orthognathic surgery to achieve my best bite, but I'm > afraid that I will have to wait and wait for my insurance to accept > my claim - if they do at all (I've heard some horror stories about > insurance). Anyway, does anyone here have any insight on this > subject? Also, I'm wondering if the orthodontist has anything to do > with the insurance issue or is everything totally handled by the oral > surgeon? Is it possible to get the braces on before the surgery has > been accepted by the insurance? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 Hi I work for a doctor and do the insurance/billing. First of all I do not understand why the doctor's office is telling you that they are treating your insurance as out of network if he is an in network doctor. I am going to assume since your question is regarding the copay then maybe the physician's office terminated their contract with Cigna. You do not pay a copay if the doctor is out of network. Copays only apply to in network visits. Normally for out of network you have an annual deductible and coinsurance which is usually 20-30%. I would hope that the copays you paid in the past are being applied to the out of network amounts owed. I really doubt that you are going to get someone at Cigna to write a personalized letter for you, but I suppose it is worth a try. My suggestion is that first you double check that your doctor no longer participates in Cigna as in network. Second, if you have an explanation of benefits (EOB) from a past visit that shows that their was no $30 applied to the copay column than maybe they can use that as proof. Third, they should know this. They should not even have to make a call to Cigna to answer this question. She probably didn't even ask the right question when she had them on the phone. I wouldn't want to pay the $30 up front either. Not that it is a lot, but it is just the principle. If you still have problems, I would have the girl call in front of you so you can get on the phone while in the office. JoAnn Mom to and Kenny (10/22/03) DDB 12/24 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 Okay, I really don't know what to do at this point so let me ask you guys for advice. Originally, my insurance covered Dr. Herzenberg as " in network " until 6 months later when they decided to tell me that they wouldn't cover him as " in network " even though he is " in network " . Anyway, I have now been told several times now by my insurance company that in utilizing my " out of network " benefits I should no longer be obligated to pay co-pays at Dr. Herzenberg's office which by the way is $30.00 (which is kind of alot of money!). Well, I explained this to the receptionist and of course she knows nothing about insurance so she calls the " Financial Specialist " who tells me that she has no idea what I am talking about so she went to her office to call Cigna and find out if I have to pay the co-pay. In the meantime, I called Cigna from my cell phone and asked them the same question (for the 4th time) and they said NO COPAY! She came out of the office (an hour later) and said that Cigna told her I have to pay the $30.00 copay and Christian would NOT be seen if I didn't pay it. Do you think that, if I request it, my insurance would send a letter saying I don't have to pay it to them? It's bad enough that I have to pay thousands of dollars out of pocket now because of the " in network/out of network " thing and I would rather not pay the copay if I don't have to. Mommy to (12-17-98) and Christian (1-30-04) LCF - DBB (nights only) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 I would definitely get a letter and have them address it to the doctor's office but have it sent to you. That way you can make a copy of it and then send it in to them. The only question that I would have to ask is, does the $$ reset to 0 for 2005. Gerace cgerace@...> wrote:Okay, I really don't know what to do at this point so let me ask you guys for advice. Originally, my insurance covered Dr. Herzenberg as " in network " until 6 months later when they decided to tell me that they wouldn't cover him as " in network " even though he is " in network " . Anyway, I have now been told several times now by my insurance company that in utilizing my " out of network " benefits I should no longer be obligated to pay co-pays at Dr. Herzenberg's office which by the way is $30.00 (which is kind of alot of money!). Well, I explained this to the receptionist and of course she knows nothing about insurance so she calls the " Financial Specialist " who tells me that she has no idea what I am talking about so she went to her office to call Cigna and find out if I have to pay the co-pay. In the meantime, I called Cigna from my cell phone and asked them the same question (for the 4th time) and they said NO COPAY! She came out of the office (an hour later) and said that Cigna told her I have to pay the $30.00 copay and Christian would NOT be seen if I didn't pay it. Do you think that, if I request it, my insurance would send a letter saying I don't have to pay it to them? It's bad enough that I have to pay thousands of dollars out of pocket now because of the " in network/out of network " thing and I would rather not pay the copay if I don't have to. Mommy to (12-17-98) and Christian (1-30-04) LCF - DBB (nights only) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 I am trying to figure that one out also. I am going to call them again first thing in the a.m. tomorrow to get a letter. Mommy to (12-17-98) and Christian (1-30-04) LCF - DBB (nights only) _____ From: Dawn-Marie Sent: Monday, January 17, 2005 3:44 PM To: nosurgery4clubfoot Subject: Re: insurance question I would definitely get a letter and have them address it to the doctor's office but have it sent to you. That way you can make a copy of it and then send it in to them. The only question that I would have to ask is, does the $$ reset to 0 for 2005. Gerace cgerace@...> wrote:Okay, I really don't know what to do at this point so let me ask you guys for advice. Originally, my insurance covered Dr. Herzenberg as " in network " until 6 months later when they decided to tell me that they wouldn't cover him as " in network " even though he is " in network " . Anyway, I have now been told several times now by my insurance company that in utilizing my " out of network " benefits I should no longer be obligated to pay co-pays at Dr. Herzenberg's office which by the way is $30.00 (which is kind of alot of money!). Well, I explained this to the receptionist and of course she knows nothing about insurance so she calls the " Financial Specialist " who tells me that she has no idea what I am talking about so she went to her office to call Cigna and find out if I have to pay the co-pay. In the meantime, I called Cigna from my cell phone and asked them the same question (for the 4th time) and they said NO COPAY! She came out of the office (an hour later) and said that Cigna told her I have to pay the $30.00 copay and Christian would NOT be seen if I didn't pay it. Do you think that, if I request it, my insurance would send a letter saying I don't have to pay it to them? It's bad enough that I have to pay thousands of dollars out of pocket now because of the " in network/out of network " thing and I would rather not pay the copay if I don't have to. Mommy to (12-17-98) and Christian (1-30-04) LCF - DBB (nights only) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 Probably what is happening is that CIGNA is not saying you have to pay the copay. What happens when someone is in network means that the practice has agreed to accept the payment from your insurance w/out billing you more. Wether your insurance says Dr H's office is out of network or not.......they do not decide about you paying the copayment. It is up to the Drs. office to decide wether or not they want to accept your insurance w/out charging you additional money. I have this problem alot because my insurance (through the military) will not pay the ridiculous amounts alot of institutions charge. For example a hospital will bill any insurance company the same amount for an xray. It would cost you $100 and me $100. Depending on your insur. provider mine may pay the hospital only $35. and yours may pay them $85 for the same exact procedure. If the Drs office is considered " in network " this means that thay have an agreement to accept our insurance w'out billing us for the extra amount. The prices are agreed on beforhand. My insurance pays low so alot of people will not accept it w/out copay. When I went to Dr Frick last month they said they do not accept tricare w/out $50 copay at the time of visit. It was a fight to get them to even schedule me. I ended up talking w/Dr Fricks nurse and she " handled " it.......when I showed up the receptionist didn't even ask for the copay. I will probably be billed for what my insurance doesn't pay though. This is my understanding though.........what I told you could be diff. with other insurance but I was told it is basically true with any insurance. ( I would suggest asking for a patiend representative next time) > Okay, I really don't know what to do at this point so let me ask you guys > for advice. Originally, my insurance covered Dr. Herzenberg as " in network " > until 6 months later when they decided to tell me that they wouldn't cover > him as " in network " even though he is " in network " . Anyway, I have now been > told several times now by my insurance company that in utilizing my " out of > network " benefits I should no longer be obligated to pay co-pays at Dr. > Herzenberg's office which by the way is $30.00 (which is kind of alot of > money!). Well, I explained this to the receptionist and of course she knows > nothing about insurance so she calls the " Financial Specialist " who tells me > that she has no idea what I am talking about so she went to her office to > call Cigna and find out if I have to pay the co-pay. In the meantime, I > called Cigna from my cell phone and asked them the same question (for the > 4th time) and they said NO COPAY! She came out of the office (an hour > later) and said that Cigna told her I have to pay the $30.00 copay and > Christian would NOT be seen if I didn't pay it. Do you think that, if I > request it, my insurance would send a letter saying I don't have to pay it > to them? It's bad enough that I have to pay thousands of dollars out of > pocket now because of the " in network/out of network " thing and I would > rather not pay the copay if I don't have to. > > > > > > > > Mommy to (12-17-98) and > > Christian (1-30-04) LCF - DBB (nights only) > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 I get what you're saying, you shouldn't have to pay for the co-pay at the time of the visit if the insurance company says that's the way it is. But I don't think that either way, you're loosing money because if you pay the $30 and then the insurance company pay the portion they feel responsible for (how does an in network Dr. become an out of network Dr. even if they're still in the network anyway??) they will apply that $30 to the balance due which will reduce what you have to pay as your portion. I'd still fight the pay now or pay later thing, I prefer to be billed most of the time because then I can make payment arrangements with the billing department and pay large medical bills off slowly that way. Kori At 12:36 PM 1/17/2005, you wrote: >Okay, I really don't know what to do at this point so let me ask you guys >for advice. Originally, my insurance covered Dr. Herzenberg as " in network " >until 6 months later when they decided to tell me that they wouldn't cover >him as " in network " even though he is " in network " . Anyway, I have now been >told several times now by my insurance company that in utilizing my " out of >network " benefits I should no longer be obligated to pay co-pays at Dr. >Herzenberg's office which by the way is $30.00 (which is kind of alot of >money!). Well, I explained this to the receptionist and of course she knows >nothing about insurance so she calls the " Financial Specialist " who tells me >that she has no idea what I am talking about so she went to her office to >call Cigna and find out if I have to pay the co-pay. In the meantime, I >called Cigna from my cell phone and asked them the same question (for the >4th time) and they said NO COPAY! She came out of the office (an hour >later) and said that Cigna told her I have to pay the $30.00 copay and >Christian would NOT be seen if I didn't pay it. Do you think that, if I >request it, my insurance would send a letter saying I don't have to pay it >to them? It's bad enough that I have to pay thousands of dollars out of >pocket now because of the " in network/out of network " thing and I would >rather not pay the copay if I don't have to. > > > > > > > >Mommy to (12-17-98) and > >Christian (1-30-04) LCF - DBB (nights only) > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 , I don't have an answer to your specific question, but I can tell you in my experience, you have to get the people's names (and phone numbers if possible) of who tells you what at the insurance company. Often times, in a big company, one hand does not know what the other is doing. I have been burned before. Take your time with them when you call back and make sure that they answer all your questions and get their name too. A letter does seem like it would be very beneficial as well. Caroline > Okay, I really don't know what to do at this point so let me ask you guys > for advice. Originally, my insurance covered Dr. Herzenberg as " in network " > until 6 months later when they decided to tell me that they wouldn't cover > him as " in network " even though he is " in network " . Anyway, I have now been > told several times now by my insurance company that in utilizing my " out of > network " benefits I should no longer be obligated to pay co-pays at Dr. > Herzenberg's office which by the way is $30.00 (which is kind of alot of > money!). Well, I explained this to the receptionist and of course she knows > nothing about insurance so she calls the " Financial Specialist " who tells me > that she has no idea what I am talking about so she went to her office to > call Cigna and find out if I have to pay the co-pay. In the meantime, I > called Cigna from my cell phone and asked them the same question (for the > 4th time) and they said NO COPAY! She came out of the office (an hour > later) and said that Cigna told her I have to pay the $30.00 copay and > Christian would NOT be seen if I didn't pay it. Do you think that, if I > request it, my insurance would send a letter saying I don't have to pay it > to them? It's bad enough that I have to pay thousands of dollars out of > pocket now because of the " in network/out of network " thing and I would > rather not pay the copay if I don't have to. > > > > > > > > Mommy to (12-17-98) and > > Christian (1-30-04) LCF - DBB (nights only) > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 you mean you don't want to pay more money than you have to??? I always love to pay as much money up front as I can whether I owe it or not, you know, we are made of money after all!! (that was slight sarcasm, I realize it's hard to come across that way in print! LOL) I would check to see if your co pays start over again with the new year. We had that same issue with physical therapy, and now that it's 2005 we have to start all over. yay! and next time you call, get the persons name and then have the docs office contact that person directly. But a letter is most definitely a good idea! In writing is always a good way to go! > Okay, I really don't know what to do at this point so let me ask you guys > for advice. Originally, my insurance covered Dr. Herzenberg as " in network " > until 6 months later when they decided to tell me that they wouldn't cover > him as " in network " even though he is " in network " . Anyway, I have now been > told several times now by my insurance company that in utilizing my " out of > network " benefits I should no longer be obligated to pay co-pays at Dr. > Herzenberg's office which by the way is $30.00 (which is kind of alot of > money!). Well, I explained this to the receptionist and of course she knows > nothing about insurance so she calls the " Financial Specialist " who tells me > that she has no idea what I am talking about so she went to her office to > call Cigna and find out if I have to pay the co-pay. In the meantime, I > called Cigna from my cell phone and asked them the same question (for the > 4th time) and they said NO COPAY! She came out of the office (an hour > later) and said that Cigna told her I have to pay the $30.00 copay and > Christian would NOT be seen if I didn't pay it. Do you think that, if I > request it, my insurance would send a letter saying I don't have to pay it > to them? It's bad enough that I have to pay thousands of dollars out of > pocket now because of the " in network/out of network " thing and I would > rather not pay the copay if I don't have to. > > > > > > > > Mommy to (12-17-98) and > > Christian (1-30-04) LCF - DBB (nights only) > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 Hi Joann, The whole situation doesn't make any sense whatsoever. He is still in network for Cigna, however, because I live in New Jersey and he is in land we both must participate in the " Seamless Plan " . I do, but Cigna said, he doesn't participate in this plan. So, he is in network and I can treat with doctors outside of New Jersey but he can't treat patients outside of land.....you probably thinking..what???? LOL THAT IS THE BIGGEST B#@$(*(*# STORY I HAVE EVER HEARD IN MY LIFE! I have yet to see my $30.00 applied to anything and we have been there about 10 or 12 times which adds up after awhile! First thing I am going to do tomorrow is call the billing office and find out if my copay is being applied to my bill! THANKS FOR YOUR HELP :-) Mommy to (12-17-98) and Christian (1-30-04) LCF - DBB (nights only) _____ From: joannertle@... Sent: Monday, January 17, 2005 6:51 PM To: nosurgery4clubfoot Subject: Re: insurance question Hi I work for a doctor and do the insurance/billing. First of all I do not understand why the doctor's office is telling you that they are treating your insurance as out of network if he is an in network doctor. I am going to assume since your question is regarding the copay then maybe the physician's office terminated their contract with Cigna. You do not pay a copay if the doctor is out of network. Copays only apply to in network visits. Normally for out of network you have an annual deductible and coinsurance which is usually 20-30%. I would hope that the copays you paid in the past are being applied to the out of network amounts owed. I really doubt that you are going to get someone at Cigna to write a personalized letter for you, but I suppose it is worth a try. My suggestion is that first you double check that your doctor no longer participates in Cigna as in network. Second, if you have an explanation of benefits (EOB) from a past visit that shows that their was no $30 applied to the copay column than maybe they can use that as proof. Third, they should know this. They should not even have to make a call to Cigna to answer this question. She probably didn't even ask the right question when she had them on the phone. I wouldn't want to pay the $30 up front either. Not that it is a lot, but it is just the principle. If you still have problems, I would have the girl call in front of you so you can get on the phone while in the office. JoAnn Mom to and Kenny (10/22/03) DDB 12/24 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 , That is the weirdest thing I have ever heard! I think insurance companies have rooms full of people writing codes & rules that contradict each other to make us poor people run in circles just trying to get covered! I was going to say it sounded to me (not that I know much) like the insurance co was saying the doc is out of network, and the doc's office is trying to treat you like you're in network. Whatever! I hope you get it figured out! , mommy of: Guinevere, on, Ava 8/4/04 right CF DBB 23/7 > Hi Joann, > > > > The whole situation doesn't make any sense whatsoever. He is still in > network for Cigna, however, because I live in New Jersey and he is in > land we both must participate in the " Seamless Plan " . I do, but Cigna > said, he doesn't participate in this plan. So, he is in network and I can > treat with doctors outside of New Jersey but he can't treat patients outside > of land.....you probably thinking..what???? LOL THAT IS THE BIGGEST > B#@$(*(*# STORY I HAVE EVER HEARD IN MY LIFE! > > > > I have yet to see my $30.00 applied to anything and we have been there about > 10 or 12 times which adds up after awhile! First thing I am going to do > tomorrow is call the billing office and find out if my copay is being > applied to my bill! > > > > THANKS FOR YOUR HELP :-) > > > > > > Mommy to (12-17-98) and > > Christian (1-30-04) LCF - DBB (nights only) > > _____ > > From: joannertle@a... [mailto:joannertle@a...] > Sent: Monday, January 17, 2005 6:51 PM > To: nosurgery4clubfoot > Subject: Re: insurance question > > > > Hi > > I work for a doctor and do the insurance/billing. First of all I do not > understand why the doctor's office is telling you that they are treating > your > insurance as out of network if he is an in network doctor. I am going to > assume > since your question is regarding the copay then maybe the physician's office > > terminated their contract with Cigna. You do not pay a copay if the doctor > is > out of network. Copays only apply to in network visits. Normally for out of > > network you have an annual deductible and coinsurance which is usually > 20-30%. > I would hope that the copays you paid in the past are being applied to the > out of network amounts owed. I really doubt that you are going to get > someone > at Cigna to write a personalized letter for you, but I suppose it is worth > a > try. My suggestion is that first you double check that your doctor no > longer > participates in Cigna as in network. Second, if you have an explanation of > benefits (EOB) from a past visit that shows that their was no $30 applied to > > the copay column than maybe they can use that as proof. Third, they should > know > this. They should not even have to make a call to Cigna to answer this > question. She probably didn't even ask the right question when she had them > on the > phone. I wouldn't want to pay the $30 up front either. Not that it is a > lot, > but it is just the principle. If you still have problems, I would have the > girl call in front of you so you can get on the phone while in the office. > > JoAnn Mom to and Kenny (10/22/03) DDB 12/24 > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 17, 2005 Report Share Posted January 17, 2005 Get the name of the person that you spoke with at Cigna and the name of the person that the Dr. Herzenberg's office spoke to at Cigna and then write a letter (or an email) and get to the bottom of this at once! Daiga > Okay, I really don't know what to do at this point so let me ask you guys > for advice. Originally, my insurance covered Dr. Herzenberg as " in network " > until 6 months later when they decided to tell me that they wouldn't cover > him as " in network " even though he is " in network " . Anyway, I have now been > told several times now by my insurance company that in utilizing my " out of > network " benefits I should no longer be obligated to pay co-pays at Dr. > Herzenberg's office which by the way is $30.00 (which is kind of alot of > money!). Well, I explained this to the receptionist and of course she knows > nothing about insurance so she calls the " Financial Specialist " who tells me > that she has no idea what I am talking about so she went to her office to > call Cigna and find out if I have to pay the co-pay. In the meantime, I > called Cigna from my cell phone and asked them the same question (for the > 4th time) and they said NO COPAY! She came out of the office (an hour > later) and said that Cigna told her I have to pay the $30.00 copay and > Christian would NOT be seen if I didn't pay it. Do you think that, if I > request it, my insurance would send a letter saying I don't have to pay it > to them? It's bad enough that I have to pay thousands of dollars out of > pocket now because of the " in network/out of network " thing and I would > rather not pay the copay if I don't have to. > > > > > > > > Mommy to (12-17-98) and > > Christian (1-30-04) LCF - DBB (nights only) > > > > > > Quote Link to comment Share on other sites More sharing options...
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