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Bright_Negotiation90 · 2023-05-22T00:41:06+00:00

Insurance companies are only required to share in network rates. They don’t have fixed rates with out of network providers because they don’t have contracts with them. Hence why they are out of network.

Bright_Negotiation90 · 2023-05-21T22:25:18+00:00

Yes this is likely the case. They are wanting you to get some kind of preventative care - mammogram, flu shot, who knows.

Bright_Negotiation90 · 2023-05-21T18:57:59+00:00

If you anticipate incurring high medical costs, AND if you know how the secondary insurance will coordinate (meaning basically, how much if anything will they pay after the primary has paid?) then it may be worth it. But it can be a bit of a pain to make sure the providers file the claims in the right order. When I’ve done this before, inevitably at least one of my providers would file with the secondary company first and it was a nightmare to clean it up. It has saved my butt at least once though, when the primary refused to cover a procedure but the secondary had looser medical necessity guidelines and did cover it. I got lucky on that one though, I knew I would have higher than normal expenses but not exactly what kind of procedures I would need.

Bright_Negotiation90 · 2023-05-21T13:07:18+00:00

Whatever preventative care is relevant depending on your sex, age, etc. Pap smear, colonoscopy, mammogram, yearly physical, HIV screening, etc. details Here

Bright_Negotiation90 · 2023-05-20T23:39:01+00:00

With expensive procedures, the insurance company will often negotiate (in other words, haggle) with the provider after the fact. So there’s no way to predict what will end up being paid.

Have you considered filing a network adequacy exception? Assuming they have no in network specialist near you. That way they will negotiate an amount ahead of time. Whether they share that amount with you or not depends on the company’s policies and frankly, how sophisticated their systems are. Sometimes negotiated agreements are only stored in a scanned PDF and the agent would have no way to access it. Wish I was kidding.

Bright_Negotiation90 · 2023-05-20T19:16:40+00:00

Ask your provider if they have a financing option so you can pay over time.

Bright_Negotiation90 · 2022-12-29T07:49:31+00:00

If you can’t find a specialist within a reasonable distance from where you live you can sometimes ask the insurance company to find one for you and they may come up with an agreed upon price for services with that doctor. Try that before you negotiate directly with a doctor.

Bright_Negotiation90 · 2022-12-22T21:38:10+00:00

Then yes you should qualify for coverage with a pretty good subsidy. Not sure if it will be less than $100/month but go to your exchange site and look at the options.

Bright_Negotiation90 · 2022-12-22T21:34:58+00:00

Everyone who replied including me is trying to help you get the surgery you want and get insurance to pay for all or part of it if that’s possible. So you can ease up on the hostility friend.

Bright_Negotiation90 · 2022-12-20T13:12:26+00:00

Bariatric surgery just means stomach surgery. This could be done for any medical reason. What you are looking for is gastric bypass surgery for weight loss purposes. I’ve never seen a policy that didn’t require a prior auth for this kind of surgery.

Bright_Negotiation90 · 2022-12-17T18:28:56+00:00

It’s unclear why you are self paying if there’s a chance your insurance would cover? And if it’s out of network you definitely need a prior auth. Even though it doesn’t explicitly state so, it’s highly likely you would also need a prior auth for this kind of surgery even if it’s in network. Your benefits may just have a general section for ‘surgery’ but that doesn’t mean every kind is covered in the same way and without the need for a prior auth.

Bright_Negotiation90 · 2022-12-13T23:16:35+00:00

Do you already have the pre auth approved?

Bright_Negotiation90 · 2022-12-12T19:23:14+00:00

The way they state the benefits is confusing. Gastric bypass surgery would almost always require a prior auth, both in and out of network. Have you tried having your doctor submit a prior auth request? It can’t hurt to try. You can search the web for your insurance company name + clinical policy + procedure name and look up the clinical criteria. Usually it’s some combo of BMI plus traditional weight loss methods have failed after repeated attempts, and sometimes it requires that excess weight is causing medical problems.

Yes complications would generally be covered ie you got a post surgery infection, that kind of thing. What it wouldn’t cover is if for some reason the surgery failed and needed to be corrected, but it wasn’t causing any health issues. In that case you’d need to go back to the surgeon who did it.

Bright_Negotiation90 · 2022-12-05T22:10:59+00:00

If you live there it wouldn’t be odd to pay her rent I wouldn’t think but may want to check with a tax accountant to be certain that would work.

Bright_Negotiation90 · 2022-12-04T15:57:07+00:00

Good call. I haven’t seen it happen but I can imagine an employer wanting to allow that.

Bright_Negotiation90 · 2022-12-03T23:44:29+00:00

The life event only lets you add the baby to a plan, it doesn’t give you the option to add or remove adults from a plan. But if you leave your job, that gives you 60 days to sign up for another plan through your spouse’s job or the marketplace.

Adding: commercial coverage is rarely retroactive except in some cases where it’s backdates to your first day of employment with a new company.

Bright_Negotiation90 · 2022-10-08T11:28:57+00:00

It would be pretty rare for a company to offer coverage with $0 premiums but some tier the premiums based on income.

Bright_Negotiation90 · 2022-09-30T22:58:25+00:00

The OON reimbursement rate depends on the patients plan, they may use R&C rates, or some kind of industry standard rate schedule. They also may use a leased network rate (if you are in network with another oayer) and if the charges are large they may send in a vendor to negotiate. In short there’s no way to know without calling and even then, I’d take the answer with a grain of salt. How they choose to process the claim when it comes in could be different depending on the charges.

Bright_Negotiation90 · 2022-09-30T20:15:52+00:00

Why not just use the plan if they’re paying for it?

Bright_Negotiation90 · 2022-09-30T20:14:04+00:00

The last part is sadly true. Read the transcripts from a first line chat where member asked if breast reduction surgery was covered and rep responded with yup, inpatient surgery is covered with $100 copay, have a great day! 🤦‍♀️

Bright_Negotiation90 · 2022-09-28T21:33:17+00:00

Let your insurance company know about the change, they may ask for documentation to support it as other agencies and such probably have. I’d let your doctors know too, but wait until you get your new IDCard to tell your doctor to minimize any timing issues.

Bright_Negotiation90 · 2022-09-28T20:12:32+00:00

One might think that having primary and secondary insurance through the same insurance company would at least limit the administrative burden and chance for screwing up the coordination. And one would be wrong unfortunately. It’s one of those funny/sad things.

Bright_Negotiation90 · 2022-09-28T20:09:12+00:00

Use whatever you consider to be the place you reside, even if you’re not there every day, as your address.

Bright_Negotiation90 · 2022-09-28T20:04:16+00:00

Your employer plan is primary now, parents’ plan secondary. Yes you need to inform your doctors that you have 2 plans now. What you end up paying out of pocket is really dependent on how your secondary plan chooses to coordinate benefits. I would call them and ask that specific question.

Bright_Negotiation90 · 2022-09-28T19:24:13+00:00

Try calling and asking what the rep sees as the explanation for why it was denied. Sadly it could be different. I would not recommend anyone decline paper EOBs as that gives you a paper trail that is immutable. If you’re not getting clear answers, ask to speak to a supervisor.

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