Do you need experimental surgery or this is what your insurance company called it. Is it really experimental surgery? How many times has it been performed? Who performed it? Before you hear from your medical insurance the procedure your doctor wants to perform is considered experimental, too expensive, the statistics are low for the surgery to be beneficial. Think again.
Your medical insurance said they will not pay for the surgery what is your next step?
Calm down think logically. You need to appeal!! You need this surgery to save your life or limb.
These are the questions you need to ask yourself?
1. Is this the surgical procedure I really need?
2. Is there another surgery which is better?
3. Is the surgeon that really can perform this particular surgery on your medical plan or is the surgeon out of network?
4. What will be the entire cost of the surgery?
5. HOW DO I GET MY MEDICAL INSURANCE TO PAY FOR THE SURGICAL PROCEDURE?
BREAK DOWN OF CHARGES:
a. Charge of operating room?
b. Charge for surgeon?
c. Charge for assistant surgeon?
d. Charge for anesthesiologist?
e. Charge for Laboratory?
f. Charge for X-rays?
g. Charge for unknown?
1. You can get this information simply by calling your doctor's office. There will be somebody whose job it is to get this information to you.
With this information in hand you will now have a substantial plan in hand.
2. Another vital part of your appeal is getting the names of people who have had this experimental procedure performed and your insurance company has paid for it. You will need a list of their names, date of surgery, the name of surgeon, the surgical procedure performed.
You can get this information by requesting it online at any of the popular websites. Make sure you include in your request why you need this information. Include your contact information (name and email address)
This is the time to think outside of the box to get all the information you need, what phone calls to make, and what websites can get you the information you need.
3. If the surgeon you want actually performs this particular surgical procedure, is on another medical plan, you must get this same estimate from that physician's office.
You can then do a cost comparison.
In an appeal letter in which the surgical procedure you need has been denied, ask the insurance company what form of MEDICAL NECESSITY information they need.
4. What is in your contract about this type of appeal procedure?
You can get some of this information off the internet in your medical insurance company's website. If you can't get everything you need call and ask them to mail it. Make sure whatever you receive you send back to them in the appeal package.
5. Always send medical records with your appeal. You can request them in writing from your physicians, hospital, x-ray, lab, ambulance, etc.
6.. Fax your appeal letter and all your documents the more documents the better make it at least 20 plus pages.
Get to the top person in your medical insurance company.
Do your homework.
Use your computer or start calling and asking for the CEO's phone number, fax number and email #.
The president, vice presidents any body in power.
Then fax all this information marked Urgent Expedite Immediately and I would add Personal and Confidential.
Fax this at midnight on Sunday night.
Fax it to everybody you can get their fax #s.
Make sure you change the Fax information sheet.
The name of the person being faxed, title, your name, Appeal Letter for Specific Surgery
CPT and ICD numbers. CPT numbers is the reason for the visit Example: Doctors Visit, ICD is the medical diagnosis Example: Ear infection.
How many pages and your contact information which includes not only your name, phone number, email address, your insurance identification number.
I would also Email it all at the same time to each person. Do not forget anybody.
This is a life or death situation and you can put this appeal letter together with the guide lines above.
Remember money talks and if you can prove the surgeon you want (not the one the insurance company will give you) will be paid at the same rate, you have a great chance of getting your appeal paid.
Everything is negotiable in medical insurance. If this surgeon or hospital or both are out of net-work the payment can be negotiated by the insurance companies.
Experimental Surgery Authorized What About the Doctor
The experimental surgical procedure has been approved. Yeah!
Now is your battle really over? If this is experimental surgery there are not many doctor's which will do this very new surgical procedure.
Now is the time for you to do your homework. What is the name of the doctor who does this particular surgical procedure? How do I get this doctor to do the procedure for me and get my insurance company to pay for it, even if it is out- of-network.
Now you need to write another appeal letter.
You do a cost comparison between the doctor your insurance company picked and the doctor you want to perform your surgical procedure. See above.
You can get statements in writing (if possible) from physicians who are picked to perform this experimental procedure to say they do not do this kind of procedure they work in another part of the body. They make charge you.
The important thing is get your surgical procedure authorized, get the right physician and have a great life. Thank you for reading my article. Please feel free to read any of my various articles on numerous subjects. Linda E. Meckler copyright
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