So I went to an OMS, Dr. P within my network today. This was at the UCSF hospital which is a teaching facility. The surgeon didn't really do much. He walked in didn't say hello or introduce himself, even though this was the first time I'd seen him. He started talking to the observing students. I tried to interject and offer up some useful information but he continued to cut me off. When I was able to get a word in I let the surgeon know that I had an approval for the same reason I was there and I was seeing him because I wanted to stay within my network. He got on me and said that this was information that I needed to share with him right away. I was a little taken back as he didn't really even talk to me or want to hear what I was trying to say earlier. Moving forward from that point the resident surgeon, Dr. J took over. He did all photos and measurements.
Even thought Dr. P was distant and possibly insulting I like the fact that his experience plus the eyes of many students is what I would be getting. Students work really had to impress their professors. The surgery would be completed by the Dr. P and not a student.
I have a followup appointment April 23, 2009. This whole process is taking a really long time.
On another note, I called the Texas Department of Insurance (TDI) about my insurance company not suppling the benefit booklet so I find out what the allowable maximum would be for my treatement. TDI was not that helpful over the phone. All they said is that I should file a complaint which would take 4-6 weeks before I got any results. I did file a complaint. Now I just have to sit and wait for their reply. I feel kind of like a rat/ whistle blow. I know that I should not feel that way but I do. I also feel ripped off because I have to spend a lot time that could be spend on other things.
Tuesday, March 17, 2009
Tuesday, March 3, 2009
Insurance - in network or out of network
So last time I was excited to be approved for my surgery. Well there is always a ketch 21 with insurance companies. So my coverage is "Bluecross Blueshield of Texas PPO". Which is pretty simple to understand if you live outside California. In the state California Bluecross and Blueshield are different medical providers/companies. I of corse live in California. I apparently am a member of Bluecross PPO or Blue card PPO. Which would have been good to know months ago when I went to see my OMS. The OMS office didn't know until I told them last week that they where out of my network. The OMS didn't know because they are covered by Blueshield but has to send their claims to Bluecross Blueshield of Texas PPO for processing. This so very odd, how do people trust or understand what they are covered by or for when things like this happen? I am pretty sure that I am not the only one experiencing this confusion, unrest and distrust of insurance companies.
Back to the letter of approval. The letter indicated that they I would have to reach my min deductible then they would pay 90% of the allowable max. After I met my max deductible they would pay 100% of the allowable maximum, if the doctor was in the network. If the surgeon is out of my network they'll pay 75% of the allowable max once I reach the min deductible. Once I reach my max deductible they will pay 100% of the allowable max.
"WHAT IS THE ALLOWABLE MAXIMUM?"
I called the medical insurance company to see what the amount of the maximum allowable would be for my procedure. Guess what not one person could tell me that information. I called a total of 4 times and got the same answer each time. The customer service agents did not have this information . They said to go to the benefit booklet which you have to get from your companies admin office as they did not have any copies and could not order you one. The admin office only had the"summary of benefits" This indicated the percentages that would be covered but was only a summary and did not have $ figures.
The OMS office finally got a $ figure form one agent the would not send a written copy. The dollar amount for a $75,000 for my 3 treatment procedures is $4705.98. That's right they said they would pay less then 7% of my surgery.
I have decided to try a doctor within my network. The only ones that specialized in adult orthognathic surgery and within 30 miles of my home are at UCSF. I did some research on this Oral Maxillofacial office has a record for keeping bad records, keeping people waiting for 1 hour before seeing them and they don't have real communication between the student doctors and the residents. I called UCSF yesterday to schedule and appointment with one of the doctors in-my-network. The schedular pushed me into taking an appointment with Dr. C... for March 13, 2009 saying that this sergeon usually has the same contracts as dr. Bast (even though that is who I asked for). Dr C... was not covered by my insurance so now I have to wait till April 7.
I really want to get the finances in order without owing a sports car at the end of this but the way this health care system is designed my wish seems impossible.
By the way if I didn't mention this before I am Canadian and really miss my public health care system where the costs of medical treatment are reasonable.
Back to the letter of approval. The letter indicated that they I would have to reach my min deductible then they would pay 90% of the allowable max. After I met my max deductible they would pay 100% of the allowable maximum, if the doctor was in the network. If the surgeon is out of my network they'll pay 75% of the allowable max once I reach the min deductible. Once I reach my max deductible they will pay 100% of the allowable max.
"WHAT IS THE ALLOWABLE MAXIMUM?"
I called the medical insurance company to see what the amount of the maximum allowable would be for my procedure. Guess what not one person could tell me that information. I called a total of 4 times and got the same answer each time. The customer service agents did not have this information . They said to go to the benefit booklet which you have to get from your companies admin office as they did not have any copies and could not order you one. The admin office only had the"summary of benefits" This indicated the percentages that would be covered but was only a summary and did not have $ figures.
The OMS office finally got a $ figure form one agent the would not send a written copy. The dollar amount for a $75,000 for my 3 treatment procedures is $4705.98. That's right they said they would pay less then 7% of my surgery.
I have decided to try a doctor within my network. The only ones that specialized in adult orthognathic surgery and within 30 miles of my home are at UCSF. I did some research on this Oral Maxillofacial office has a record for keeping bad records, keeping people waiting for 1 hour before seeing them and they don't have real communication between the student doctors and the residents. I called UCSF yesterday to schedule and appointment with one of the doctors in-my-network. The schedular pushed me into taking an appointment with Dr. C... for March 13, 2009 saying that this sergeon usually has the same contracts as dr. Bast (even though that is who I asked for). Dr C... was not covered by my insurance so now I have to wait till April 7.
I really want to get the finances in order without owing a sports car at the end of this but the way this health care system is designed my wish seems impossible.
By the way if I didn't mention this before I am Canadian and really miss my public health care system where the costs of medical treatment are reasonable.
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