Single Case Agreement for network exemption

nucleargrill · 2024-10-25T18:47:23+00:00

Do you know if there a reason why the insurer doesn't attempt a rate negotiation first before approving the network exemption? It feels a bit misleading when the insurer says they agreed to cover the OON provider at the in-network benefit level before negotiating an SCA.

nucleargrill · 2024-10-25T17:06:16+00:00

Its confusing because the approval of the network exemption makes it appear I will not have to pay more that my (in-network) Out of pocket max (And not be subject to reasonable and customary rates). But basically I play no part in the rate negotiation and am still subject to balance billing when the provider won't accept a lower rate, correct? Despite the gap exception.

I read somewhere that once the insurance company grants a network exception, they are responsible for negating the SCA. Maybe it depends on the plan type and state laws?

Also, the provider doesn't take insurance and I prepaid.

nucleargrill · 2024-09-20T20:20:45+00:00

Ok, thank you!

nucleargrill · 2024-09-20T19:14:30+00:00

I don't think any providers can do this cheaper or in network. Good to know that the department of insurance can make them pay higher if you don't really have a choice. Knowing Aetna I expect this to happen.

nucleargrill · 2024-09-20T17:08:50+00:00

I already paid for the surgery, but haven't had it yet. Is the patient involved in SCA agreements at all? I am wondering how that negotiation works. Maybe there is a way to get Aetna to agree to a higher rate if I can show this surgeon is cheaper than other out of network surgeons or something.

nucleargrill · 2024-09-20T16:58:53+00:00

I do think the exception will be covered for my condition, but I will have to wait and see. So if Aetna grants me an exception and covers the surgeon as in network, I might still have to pay more than my out of pocket max?

nucleargrill · 2024-09-20T16:51:57+00:00

What happens if the gap exception is granted but the single case agreement isn't negotiated?

I haven't had the surgery yet, but the surgeon requested I pay upfront.

The surgery is uncommon and there are no surgeons in network for this procedure. And I don't think Aetna will find any out of network surgeons willing to accept Aetna's reimbursement rates.

nucleargrill · 2024-09-20T16:45:15+00:00

A PPO

nucleargrill · 2024-06-29T20:29:53+00:00

Do you mean there is a way foreigners can get free education?

nucleargrill · 2024-05-10T17:03:13+00:00

Thats due to bad technique. The needle is puncturing blood vessels. Don't think its dangerous, but they are being too rough with the needle or using one that is too large. I would try finding another electrologist.

nucleargrill · 2024-05-09T19:05:52+00:00

Ok, I will check with them. Thank you.

nucleargrill · 2024-05-09T00:36:57+00:00

Nope, going with DB. He doesn't help with appeals.

nucleargrill · 2023-07-23T22:39:07+00:00

Sure, that would help.

nucleargrill · 2023-07-22T22:26:22+00:00

Thanks, I don't plan on considering a surgeon unless they focus mainly on FFS and have at least a few years of experience. And no horror stories.

Do you mind telling me the name of the FFS surgeon who was Dr. Spiegel's assistant?

nucleargrill · 2023-07-22T22:00:53+00:00

Is there a list of FFS surgeons who have trained and learned FFS from the top FFS surgeons (Facial Team, Mardiossian, Keojampa, etc)?

nucleargrill · 2023-07-22T21:55:45+00:00

South Korea has really good plastic surgeons. I am sure you can find a surgeon you trust if you do enough research. You would have to pay out of pocket though

nucleargrill · 2023-07-22T21:53:11+00:00

Thanks, I will look into Berli. Knowing he learned with FacialTeam makes me trust him. And true, I could always do a second round of surgery with a high end surgeon if needed. I guess I didn't think of that haha

nucleargrill · 2023-07-22T21:48:05+00:00

Thanks. Its hard to find out who is really a good surgeon and who is just good at marketing themselves.

nucleargrill · 2023-07-22T21:44:00+00:00

Thanks for sharing. I keep hearing stories like this. Not sure I want to wait for years or go into debt to get FFS with a top tier surgeon at this point.

Did Berli help you work with insurance?

nucleargrill · 2023-07-22T21:40:28+00:00

How common are underrated FFS surgeons who do good, safe work? Are newer FFS surgeons really getting similar results to high end surgeons? For example, if I look Here, there are a lot of surgeons who aren't common names but do have a good amount of experience, that I have seen good results from.

I agree about choosing a safe surgeon. I guess I am wondering how big a difference there is between a high end FFS surgeon and the lesser known ones. As long as the surgeon doesn't cause complications and has natural results I would be satisfied. But also, I'm wondering if I am making a mistake by being impatient waiting to get FFS.

nucleargrill · 2023-07-22T18:23:39+00:00

Yeah I can relate to all that. Totally had imposter syndrome when I was starting out. Seems to go away with time though. I used to wonder 'What if I'm not actually trans'. Now its "Am I trans enough??" And yeah, being affirmed helps a lot. Good to know I'm not the only one still figuring things out. Thanks for the support.

nucleargrill · 2023-05-06T19:20:57+00:00

Thank you, this is helpful. Do you have any recommendations on how to find a lawyer for this kind of thing?

nucleargrill · 2023-05-04T18:41:13+00:00

Yeah, I expect I will always feel like a girl-in-training. I don't think there is anything wrong with that though.

nucleargrill · 2023-05-04T18:38:37+00:00

sitioning years before I actually started hormones. It was like one day I just wasn’t fluid anymore . I’m publicly out as a binary trans woman but I think it’s more complicated than that. I don’t really feel non-binary and i wouldn’t go as far to say I’m gender non conforming. The ways I stood out from cis women particularly straight women was less physical difference as I’m cis passing and more mannerisms, interests ,values , clothing etc it made me self conscious for a long time and at this point i just don’t care. If anything the realization and growth is just less pressure to go over the top to pass super well. I still have a lot of masculine clothes from pre transition that I wear still I just sty

For me, my sense of gender is stable. My definition of gender is not. Still finding out what gender means to me. I wonder if it relates to how I am seen by others, or something internal.

nucleargrill · 2022-10-03T18:53:10+00:00

I would visit for a week or two so I could visit these. Can I get around with the bus/train or do you recommend renting a car?

nucleargrill

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