This is an interesting story about a woman who was told up front her cost would be $6000.00 out of pocket up front. After she had the unique surgery that would allow her to breath freely again, her claim was denied. The local news station here got involved and finally got her claim paid.
The informed patient here knew up front there was nobody in network who could perform the surgery and did all her homework, and you can see the comments regarding the CPT Codes, etc. used in the argument. Again, more than likely scoring the claim and persistence to prove there was a doctor in network through data mining and running additional algorithms in the search, failed to find any information other than what had been claimed by the patient all along. Even when you do your homework up front, algorithmic scoring on claims can still lead to a denial and then you really have a battle on your hands and thank goodness the television news team helped her out. BD
One of our viewers needed a surgery that only a handful of people in the world could do. Fortunately, one of those surgeons was here in the Valley but he was out-of-network. As this case shows, when you use a provider not in your health plan, you’ve got some legwork to do upfront.
The surgery was an amazing success. Alice’s airway was widened and her jaw repositioned. But strangely, Aetna denied her claim.
"They argued procedure codes that weren't covered and they referred me to CPT bulletins. Alice knew her out-of-network surgeon was the only one qualified for the procedure. The confusion began when Aetna ruled that they had surgeons in-network who could perform it. After more than a year, two failed appeals, and our involvement, Aetna acknowledged that Alice was right (Aetna did not have a comparable surgeon within their network) and that’s whey they paid the claim. We thank them for working with us to resolve this matter.