Insurance says doctor and hospital OUT OF NETWORK!!

We found out TODAY that my husband's Medicare Advantage plan with People's Health in Louisiana will only pay 80% of the charges for his cystoscopy that is scheduled for Monday. We thought his copay was going to be $50.00. Apparently Oschner Hospital in New Orleans is OUT OF NETWORK!

Dr. Bardot, who is the end of Urology at Oschner, is the one who was going to do it and the radical cystectomy, if needed.

There is no way we can afford the $3000 to $4000 that would be our share! And I know that there is no way we could afford the cystectomy.

We are cancelling the cysto and I am going to talk to his medical oncologist and his radiation oncologist to get their recommendations on urologists that they work with who would be in network and qualified to perform the cystectomy if he needs it. He is planning on going with the ileal conduit because of the shorter surgery time.

Insurance companies SUCK!


BTW: MD Anderson is considered out of network, too!

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25 replies. Join the discussion

Unfortunately Medicare Advantage is pretty crappy.....none of the top cancer centers will take it. Call and ask them who is in network and if noone who is near you has no particular experience with bladder cancer...fight it.

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The only problem with fighting an insurance company is that it can take months to get even the simplest issue resolved, and in the meantime precious time can be passing by for your husband.

My husband's insurance dumped the urologist that had taken care of him for two years and went with another group of doctors. This is very common with hmo's. We were very concerned, but fortunately we are more than happy with his new doctor. Maybe this will be the case with your husband, you just never know.

It's a shame that we are at the mercy of those whose only concern is saving money, but there are many out there who don't even have insurance, and have mortgaged homes and everything they have - it's not bad enough that they have cancer, but now they have to deal with facing bankruptcy, etc.

I hope that you can resolve the problem quickly and that all will turn out well. There are many experienced doctors out there, and they don't necessarily have to work at a major cancer center. But whichever way you decide to go, I wish you the best.

Gayle

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Most of the doctors around here will not take a Medicare Advantage plan. And even the few doctors that will take new patients will not accept Medicare itself, because the business will not function on what they will pay. If your husband is a veteran get him into the V.A. system. As far as the cystoscopy, most are not done in the hospital, they are done in the urologist office, and this would make it much cheaper than the hospital. When switching insurance plans one has to do the homework ahead of time and make sure they are covered to go to the doctors and hospitals that they choose.
Keith

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Sounds like it is time to change you supplementary insurance plans when the time comes. Hopefully you will find a doc that ya'll like! Let us know what happens.

Lynda

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That is terrible for you! Please don't wait around too long though, if at all possible. I pray you find a competent doctor who can do the surgery, or consider long term payments to the hospital and doctor. I understand you can sort of set the terms of the payments. Others do. I care. Avie

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One of the advantages of a HMO is that there may be no premiums. But the insurance companies make it up on the payments they make to Hospitals and Doctors. The old fashioned Medicare would have almost 100% of Hospitals as " in network" as part A is covered and Part B you pay a premium which is for Doctors. Under the old fashioned Medicare,the 20% is covered under a supplemental policy for which you also have to make premium payments and it covers the balance if you so desire. So it works, that you pay, either up front in premiums or at the end, in large copays. Nothing is free.

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OMG! I can't believe the missrepresentations in the answers to your post.

1. A Radical Cystectomy is one of the most complicated of all surgeries. It normally requires at many hours for the most limited of diversion system. It would be sheer suicide conducted in a doctor
s office.
2. Normally a radical cystectomy is performed only in a major Comprehensive Cancer Center recognized by the National Cancer Institute by an experienced team of doctors who perform a hundred or more of these operations per year.
3. Have you seen an attorney? I believe the decision of the insurance comapny is prohibited by the new Health Care Act.
4. Are you sure that the insurance isn't rejecting the claim because the hospitol you were to have the procedure performed simply isn't qualified to perform the surgery?
5. Have you contacted Comprehensive Cancer treatment Centers other than M. D. Anderson? How about Sluthwestern in Dallas? Are you sure the insurance company won't cover M. D. Anderson?
Other facilities are the University of Arizona Medical School, The University of Alabama at Birmingham.

What you need to realize is that this is perhaps one of the most complex and difficult of all surgical procedures to be performed and only teams of doctors who have performed a great many of the se operations are qualified to perform it. At the same time, I cannot believe that such a common operation would be disallowed by any insurance company. I have to believe that either there is a mistake, bad communications or an illegal act by the insurance company.

I wish you the best. I would see an attorney Monday morning.

HighlandGuy

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This cystoscopy is probably going to turn into a TURBT. The doc wanted as outpatient just in case he had to remove tumors.

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I also am having trouble sorting through the responses to your initial post.

Sorry you have encountered an issue with participation in your 'plan' It is your responsibility to know who takes your insurance and you need to know that before you schedule a procedure.

If this is the first cysto you are either early stage or have waited way long. If it is the latter you need to finding a Dr. in your network yesterday, if the former you still need a sence of urgency.

Cysto's are routinely done in the Drs. office.

Sounds to me like you are still early in the diagnostic phase.

If what you have is a real insurance policy it will be accepted almost anywhere.

Best. Scott

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I am not sure if it is Medicare Advantage. It is Peoples Health Choice plus HMO (PPO).

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i don't know what it is either...quote
"Is People's Health Choice an insurance program?
No. People’s Health Choice is not health insurance. We like to say that our service is so good that you won't believe it's NOT health insurance! Immediate repricing from hundred's of thousands of providers. It's a health benefit program with no equal. Sleep well, your with PHC now..
what does that mean?
Maybe you should contact the Patient Advocate Program.....sometimes they can weed this out.
http://www.patientadvocate.org/

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I was loosing track on this one too. Went back to susanherna past posts, and this is a cysto in preparation for what may end up being a RC. So, this is a tough situation. I would make sure the insurance company understands what the likely outcome is going to be. Maybe Dr. Bardot and Oschner patient advocacy can help convince the insurance company that it is in their best "financial" interest to allow you to have all the testing and surgery done at Oschner for all the reasons that HighlandGuy has suggested.

Prayers are with you,
Ken

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According to Peoples Health website Ochsner has 4 facilities in the network. The facility where the website says that Dr Bardot practices at 1514 Jefferson Hwy is not listed. I find this very strange that one of the group does not accept your insurance. I would call the hospital and the insurance companies on Monday and ask to speak with supervision to get some answers. If someone says that you are covered have them fax a letter to you and the doc stating that as fact.
Also Peoples Health, although they don't say it is a Advantage plan, it does "replace" Medicare and that makes it one. I believe the window of opportunity to change plans has expired until fall, but I could be wrong.

Ochsner Baptist Medical Center††
2700 Napoleon Avenue, New Orleans, LA 70115
(504) 899-9311
website

Ochsner Medical Center - Kenner††
180 West Esplanade Avenue, Kenner, LA 70065
(504) 468-8600
website

Ochsner Medical Center - NorthShore††
100 Medical Center Drive, Slidell, LA 70461
(985) 649-7070
website

Ochsner Medical Center - West Bank††
2500 Belle Chasse Highway, Gretna, LA 70056
(504) 392-3131

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All of those facilities are actually clinics not hospitals. They are part of the Peoples Health network in the New Orleans area. The Facility where Dr. Bardor practices is Oschner Hospital. They are the only Oschner that is not part of the network. I have asked Peoples health and have been told that we would have to pay 20% of the total charges.

We have cancelled the cystoscopy for Monday and I am calling the urologist who was taking card of Ted before this. He was going to do the cysto until we were referred to Dr. Bardot by his radiation oncologist. He trained under Dr. Bardot and was enthusiastic about Ted going to him.

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It is not Peoples Health Choice. It is Peoples Health. They are a provider for Medicare. THe plan that my husband is on is Peoples Health Choice Plus HMO (PPO).

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It is not a supplemental plan. It is an HMO.

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The procedure that I was talking about is a cystoscopy, not an RC. The insurance company has approved it. The only sticking point is that since it is out of network, WE would be responsible for 20% of the total charges. This could cost us anywhere from $2000 to $4000+.

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I know this is a tough time right now for you and Ted and am sorry that he needs to have this treament.

You need to make sure that you are dealing with providers that will accept your coverage so that you do not have to pay a large additional expense.

There will be good Drs. in your network and it also sounds like you are early on in the process.

So, even though you may not want to change Dr.s you may have to in order to be covered.

Hoping you and Ted find the right Dr. under your program and find the right treatment for Ted.

Best. Scott

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My husband has been fighting this since March of 2009. He has gone through 4 cystos, two of which turned into TURBTS. This was followed by four months of CIS/Gem.

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The insurance is accepted at every hospital here. BUT, if the hospital is not part of the Peoples Health network, you have to pay 20% OF THE TOTAL CHARGES.

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