Insurance policies are all different, so please be sure to check with your own policy documents in addition to using these tips. Several Nook members have been successful in getting their insurance plans to cover out-of-network providers at in-network rates for HMOs, PPOs, state insurance plans, and others.
Ablation and excision are often viewed as the same procedure by insurance companies. If their network includes surgeons who are able to provide ablation, then they may not understand the necessity of seeing an excision specialist. Tackling this kind of insurance issue often requires that you demonstrate medical necessity of the procedure and professional competence of the surgeon. Many surgeons try to perform excision, but aren’t skilled. You need to emphasize the importance of a skilled excision surgeon.
Below are a few pieces of advice from members who have successfully appealed insurance company decisions and had in-network insurance coverage for their excision surgery. Here are the key points:
- Understand YOUR policy – all insurance policies are different (even with the same carrier). BCBS for one employer may have different provisions than BCBS for another employer.
- Use your resources – the surgeon you want to see may be able to provide guidance for understanding insurance decisions and appealing those decisions.
- Be your own advocate—become educated about why excision is best, why you need it, and why skilled excision specialists are your best option for a best outcome.
- Quantify your points—insurance companies are profit based. If you can demonstrate that one excision surgery has a high likelihood of eliminating the need for several more less effective surgeries in the future, your case will be stronger.
- Build a case—utilize the free records reviews provided by many of the specialists on the Nook’s Patient-to-Patient Referral List. After a specialist has reviewed your records, they can provide documentation for why excision is best for you.
- Be organized—keep a timeline of your appeal. Be sure to keep a copy of the letters submitted on your behalf by prior doctors and potential doctors and of any correspondence from the insurance company.