Insurance Assistance Requested

[Red Rage]

I have an insurance question that I'm hoping y'all can offer some insight/info/advice on.

A little background on the situation: I'm a resident of California with an EPO (that is administrated outside of CA, though I don't think that matters in this case). I've been working on getting out-of-network coverage for surgery with Rabkin (whose office staff, particularly his financial counselor Matt, are all awesome!).

At this point, after first approving coverage via a clinical gap exception and then rescinding it, and then approving my appeal - the insurance company is now refusing to reach any sort of a fee agreement/fee contract with Rabkin's office. The best that they will offer is that they'll cover the procedure at the in-network benefit level (which in my case is a percentage of reasonable & customary), which is less than Rabkin's office informed them the charge would be.

My insurance company also advised that I would be responsible for any charges over and above reasonable & customary, though my understanding is that per the DMHC, the insurance company isn't allowed to require me to pay anything beyond the co-pay, deductible, and co-insurance that I'd be required to pay if I were seeing an in-network provider. But, does that mean that the insurance company is required to pay the non-network provider at 100% of billed charges, or does it mean that the insurance company can in fact pay only the reasonable & customary amount and require me to pay the remainder?

Any info is greatly appreciated!

[Deleted]

I'm probably in the best situation to answer you, and I'm afraid my answer is "I'm not sure." Because I don't know what it SAYS in your contract about out-of-network benefits.

IF your EPO is an in-network-only plan - in essence, an HMO - and this out-of-network benefit is a "clinical gap exception," then I believe you can only be required to pay what you would have paid if he was in-network, and the non-discounted fee that Rabkin charges is the insurance company's problem. This is what happens with Kaiser patients. Rabkin has negotiated a separate contracted rate with NorCal Kaiser, because he's ended up doing most if not all of their DSers, but he doesn't have - and doesn't HAVE to have - a contract with your insurance company.

HOWEVER - if your insurance company doesn't want to pay Rabkin his full fee, Rabkin can say no. And then you are faced with a conundrum - do you want to let them send you to Jossart or Cirangle (I'm not even sure they are still doing the DS anymore - haven't heard of any of their patients for a long time), or delay you further?

SO - this is just a suggestion. Agree to pay the extra fee, if you can - and note that Rabkin may require it up front. It should "only" be a few thousand dollars, will not go up if you require more of his time, and doing so will allow you to get your surgery NOW, before anything changes. I assume the insurance company has no problem with paying whichever hospital you would have surgery at, and THAT is the biggest expense in getting the DS - the surgeon's fee is the smallest part, and a fixed amount.

And then, after you have surgery and get the bill settled with the insurance company, and they don't pay the whole thing, appeal and take it to the DMHC to get reimbursed. I have seen several people do that with charges that the insurance company refused to pay after the surgery (in one case, they refused to pay the anesthesiologist, who was out of network - as if the patient had any choice!).

Alternatively - and actually, in addition - you should call the DMHC and find out in advance what they suggest.

And still further - before you go off and do the above, secure in the knowledge that you will win your appeal - are you SURE your insurance is covered under CA law (Knox-Keene Act)? Where YOU live is not determinative - it is where the insurance plan was "delivered" - and if your company is out of state, with certain exceptions (like if more than half of the covered employees live in CA) the KKA does NOT apply.

I know this from bitter experience - in 2007, I had Health Net, which only covered my company's CA employees (the rest were in NJ, where our company HQ was located) - and it was covered by KKA/DMHC law. Then, the company switched to BCBSNJ, with the CA employees covered on the "travel card." And suddenly, KKA/DMHC law didn't apply.

Get a copy of your contract. Call the DMHC.

[willowrayne]

I know nothing about this but don't the doctors generally agree to accept what the insurance offers, even if it is less than the regular fee? I don't think insurance ever pays the full fee.
I would ask about that angle.

Red... I am so sorry you are still struggling to get your surgery. You are such a trooper.

Sent from my Nexus 7 using proboards

[Red Rage]

Thanks for your thoughtful reply, Diana. I was hoping you'd respond. I do have a copy of the insurance contract, but it leaves me confused about a couple of things. First off, my plan is an EPO with no out-of-network benefits - as you said, essentially an HMO, though one with very generous in-network benefits. You asked if I was was sure that KKA/DMHC applies, and the truth is that I'm not sure. The company is headquartered in Massachusetts, but the medical plans offered to residents of California typically are labelled as being specific to CA - for example, when going through open enrollment, my current plan is labelled UHC EPO CA. But the SPD itself doesn't refer specifically to California in any way, which leaves me unsure whether KKA/DMHC applies.

I do know that part of the language of KKA (specifically the part that refers to the insurance company being unable, in instances where an in-network service isn't available, to require members to pay anything beyond the in-network co-pays, co-insurance, and deductibles that they'd have to pay for the same service from an in-network provider) is duplicated in the language of my contract. I'm not sure what, if anything, that means.

I do know that the text of my contract includes the following regarding how eligible expenses are determined: "When Covered Health Services are received from non-Network providers, unless you receive services as a result of an Emergency, Eligible Expenses are determined at the Claims Administrator's discretion by either (1) calculating Eligible Expenses based on available data resources of competitive fees in that geographic area, or (2) applying the negotiated rates agreed to by the non-Network provider and either the Claims Administrator or one of its vendors, affiliates or subcontractors".

Per UHC reps that I've spoken to, only the first option applies to how they arrived at what portion of Rabkin's fees they'd cover, though they can't tell me why that is. I'm trying to understand if there is any leverage that I can use to push UHC to utilize option number two in this situation.

My options at this point are to either push forward and try to get UHC to cover the entirety of Rabkin's fee (or at least get close enough to it that I can swing the cash to make up the difference), or I'll have to pull the plug on approval with Rabkin and instead request approval for surgery with Stewart, who is an in-network surgeon. Jossart is out, as I'm a former patient of his (he removed my band back in June in what was supposed to be a revision surgery, and I chose not to return to him for the rest of the surgery because he kept trying to scare me off of the DS by telling me that I'd be wearing diapers, and/or be on TPN for the rest of my life). I'm also not sure that Cirangle is still even doing DS - I think that he, like Jossart, are pushing sleeves and avoiding DS.

*sigh*

[Red Rage]

Willow, thanks love. It's been a slog, but I'll get to the promised land at some point.

You're right that many/most doctors agree to accept the insurance company's fee, but that's because either A.) the doctor is contracted by the insurance company to accept that amount, or B.) the doctor decides to accept less than the desired amount because they are looking to build a relationship with the insurance company in which volume overcomes the lowered cost. Dr. Rabkin isn't contracted with any insurance companies as far as I know, except for the fee agreement that he has with Kaiser NorCal. It's a very smart decision on his part, despite how frustrating it is on a personal level. I don't blame him a bit for doing business the way that he does, especially considering how paltry the sum is that insurance companies are willing to pay surgeons for performing DS procedures.

I'll figure it out one way or another. I'm just worried because I'm running out of contract year, which I'm sure is exactly what my insurance company is hoping for, the bastards.

[Deleted]

I think you are entitled to know in advance approximately what UHC is going to pay and what you will be responsible for. And UHC needs to be able to justify what they call UCR, when Rabkin is the ONLY DS surgeon in NorCal now.

Do you have any out-of-network benefits, OTHER than the clinical gap exception? Because if not, their language "Eligible Expenses are determined at the Claims Administrator's discretion by either (1) calculating Eligible Expenses based on available data resources of competitive fees in that geographic area, or (2) applying the negotiated rates agreed to by the non-Network provider and either the Claims Administrator or one of its vendors, affiliates or subcontractors" may be inconsistent with - and trumped by - KKA law.

If this is an HMO plan, with no out-of-network benefits, I believe they HAVE to pay whatever the out-of-network doctor demands as his usual and published fee. They can't force him to take less, and they can't force you to pay the difference.

Call the DMHC.

Speaking of which, I have emailed this exchange (anonymous as to your information) to my attorney contact at the DMHC, so you find out what you can yourself, and I'll see if the attorney can provide an answer as well.

[Deleted]

*

[songbird177]

Good luck with your case. I'm trying to get into Rabkin as well at the moment by jumping through so many hoops with my insurance. I hope it works out well for you

[Band to DS]

Red Rage & Songbird,

I don't have any information that will help with your situation, but I wanted to cheer you on & offer my support. I fought BCBSNC for almost a year before I got approved for my lap band to DS revision. Even though it's frustrating & overwhelming, don't give up. You can win if you keep going & make full use of the resources out there.

Shelli


PS - Another "exalt" to Diana for offering insurance advice to those in need.

[Red Rage]

Thanks so much for the support and encouragement, Shelli and Songbird. And thank you to Proteinsnob for the generous offer.

[songbird177]

Hey maybe we'll both get lucky enough to get Dr. Rabkin and run into each other there Here's hoping. And yes, Diana is amazing! She made my week less stressful

[Red Rage]

Diana, again - thanks for your advice, time, and effort. You asked if I had any out-of-network coverage, aside from this clinical gap exception, and the answer is no. I have zero out-of-network benefits. You mentioned that the language of UHC's contract might be inconsistent with, and trumped by, KKA. Do you happen to know which specific part of KKA you were referencing?

On your advice, I called DMHC today, and was advised to file a complaint, which I will do after the weekend when I can access the relevant paperwork from Rabkin's office.

I was a bit surprised when the DMHC rep seemed to believe that the reason I'd be eligible to file a complaint is based on the fact that UHC's Member Services advised me that there was no method of redress or grievance regarding the way in which Eligible Expenses are being calculated in my case.

We'll see how this all turns out. Frankly, I'm at the point where calls from me to UHC Member Services are met with total stonewalling on the subject of Eligible Expenses. I was told that Member Services does not know what the criteria is for how out-of-network rates are determined. Apparently that is something that Provider Services handles. But I wasn't allowed to speak to Provider Services, because I'm not a provider. So a rep from Rabkin's office called Provider Services, and was told that Provider Services doesn't actually speak to/deal with providers either. o.O

So I'll file a complaint with DMHC, and continue to push. I'm lucky that I can pay the $4,500 difference between what insurance will cover and what the doctor charges, and hope that I'm reimbursed post surgery. But since UHC won't cough up a letter to Rabkin's office advising them how much they'll cover of the surgery (a rep told me verbally during a phone call yesterday, but that isn't a contract that Rabkin can depend upon), I doubt that Rabkin will be in a position to be able to agree to perform the procedure without an official fee agreement in place. And so, I'm feeling like the likelihood that surgery will happen for me during this contract year is slim to none. Which leaves me profoundly pissed.

[JRo]

Wow Red Rage our stories are pretty darn similar!! I know it's been awhile since your post, but I would love to pick your brain and experience if you wouldn't mind...? It seems you ended up successful and so it gives me hope!!!

A little (ok, a lot) background, I had the Lap Band in 2009 and did actually lose some weight (granted I had never worked harder in my life) but after a few years the adjustments made no difference and I was just gaining. So it was removed 5/2014 and I had the VSG 8/2014 (those 3 surgeries were with Coirin in Modesto). I lost about 38 pounds total with the VSG, and honestly once my stomach was healed completely (about 3 months), I had no restriction and it was like I never even had surgery. I am now back to 250 with a BMI of about 42. I went back to my follow up with Coirin and his PA suggested the DS. However, he admitted Coirin is not very experienced in it and after some air quotes and SADI mentioned, I was like HELL NAW!

So I started my research and located Dr. Rabkin. I contacted their office, and Matt was awesome. I got the steps I needed to take and took the ball and ran with it. My PCP with Sutter IPA authorized the out of network referral, however, BSC (my HMO and the paying party) declined it. Actually, initially they approved it because Rabkin is listed as Sutter doctor but for ONLY his liver transplants, so they initially screwed up and approved it at the Sutter location. I sent this all to Matt and he said unfortunately because it says Rabkin/Sutter they cant take it as an approval. I contacted my PCP and they said we authorized it for out of network, you need to harass BSC to correct it. To which I did. After a few hours of calls, they advised they had to decline it since it was Out of Network (its an auto decline) and I can file a BSC appeal. I did the BSC appeal and they declined it officially for Out of Network. Now my next step is to file a DMHC appeal. If there aren't any surgeons who can actually perform the revision to DS, then I am almost certain DMHC will approve the second opinion consultation (the actual DS will be an entirely other mountain). However, Jossart then came up on the DS Facts website and my PCP advised that since he is a Sutter in network surgeon and lists the VSG to DS revision as something he does, I need to meet with him. If he sways me from the DS, I can essentially take that as a refusal to perform the procedure I want and then there is no surgeons BUT Rabkin to perform it and DMHC will definitely approve the consultation (and hopefully, the DS).

So this is where I am now. I attend a Jossart seminar this upcoming Saturday, the 22nd. My consult with Jossart is scheduled for the 11th of September. When I made the appt, they made an off the cuff statement that Jossart saw my online inquiry submission and the RNY should be good enough, and I was like not an option for me. She responded "well that can be discussed when you see him". Part of me is thrilled because I want Rabkin and to get him I need Jossart to refuse (however, if Jossart in fact does it, insurance wise it is remarkably easier).

So my questions for you are how did you eventually get the approval with insurance to approve Rabkin even though he is out of network? Insurance appeal, or did you go all the way to DMHC? Once you got the approval to see Rabkin, how difficult was it to get approved for the DS despite the lower BMI? I only have minimal co-morbidities (edema, slight sleep apnea, joint pain, lower back pain), but no diabetes or hypertension, etc. I do have valid reasons for the DS (2 prior failures of WLS, the VSG to the DS being a natural progression, numerous diets and weight loss attempts since I was 13 - I am now 41, not being below 200 lbs since I was 18 so clearly malabsorption is the key I am missing, RNY is a temporary fix, I need a long term tool that actually works and finally, I had heart surgery as a baby and have a slow heart rate as a result - no other issues though - but the more weight I carry and the ups and downs, the harder it is to lose weight and come back from it. I need permanent!).

I really look forward to hearing from you - either by a post response or a PM!! Any insight or advice you can provide would be awesome. Thank you!!!

[goodkel]

She hasn't been here since July 10th, but according to her signature, she did get the DS from Rabkin on 12/4/12.