Never Give Up, Never Surrender!

It turns out I have quite a developed opinion regarding insurance. I think this is probably the case for most people who have encountered an expensive illness.

I thought I'd explain my philosophy so people might see why I'm so adamant about getting the in-network exception for the rest of my reconstruction reinstated.

There is only one number I care about in regards to my health insurance--the maximum out of pocket my family has to spend. It's a sure bet we'll meet it this year, as we have every year since I've gotten the bc diagnosis.

This amount is several thousand dollars--roughly the cost of a Hawaiian vacation for my husband and me.

We're happy to have coverage and happy to pay what we owe on time. But I will not pay one dime more.

In appealling this latest goofiness, I have heard too many times that I can just use our out of network benefits to finish up the work. This would trigger a whole new limit, and would mean we would pay 20% instead of 10% and there would be no caps for reasonable and customary charges--so basically, sky's the limit in addition to the in-network maximum that we will still meet.

There is no way I am going to have my family pay for two tropical vacations in one year that we will never take.

If there is not a local doctor who performs the service, our insurance allows for using a doctor who does the work and will cover that at the in-network benefit level even if they are not in-network.

Almost all plastic surgeons who do a lot of DIEPs don't contract with insurance companies as a general rule, and there is no local doctor who can do a DIEP, so getting an in-network exception is the way I have to go.

And I won't give up.

Having Troubles Getting to Second Stage

Remember when I said "peer to peer review" is the phrase you need to know if your insurance rejects your attempts for an in-network exception for DIEP reconstruction if it's not offered locally?

Well, you should also know insurance might try screwy things to keep you from getting this review, which involves their medical director chatting with your plastic surgeon.

Obviously, if that were allowed to happen I'd have a much higher chance of getting the decision overturned than if I and my dr's office wrote a letter, which the insurance co answers by letter in two weeks.

Having their medical director actually speak to my doctor seems imperative in this case, since the director thinks that I can get the second stage of a DIEP reconstruction in my town, which is simply not true. In my opinion, this person is in dire need of some education about the differences in breast reconstruction procedures after a mastectomy.

It's not like I'm asking for an elective boob job, after all.

Anyway, there are two issues that are bugging me about this.

1. When I call to get information about it, I'm told this is strictly between the dr's office and the insurance, though it affects me, the patient. They never let the patient speak with the medical director or any of that staff about the decisions. Apparently, they don't like to let the doctors speak to this person either.

2. The insurance company is saying my only line of appeal now is the letters because there is a 10-day window for asking for a peer to peer review. I have documentation that shows we did this, but they are saying that the window starts from when they made the decision--8 days before they put the decision into a letter and mailed it (a couple more days) to my dr's office. Naturally, my question is "How many, if any, peer to peer reviews do they even grant if this is their procedure?"

Now I'm left with appealling the craziness of their peer to peer process on these two fronts. What's so frustrating about this is it should be a no-brainer for insurance to approve an extension of the earlier in-network exception I had for all three stages of the DIEP back when I started this process. Those agreements come with an expiration date for some not reflective of real life reason, and that's why my doctor applied for the extension.

Trust me, I wanted to wrap up all three phases of this DIEP process as quickly as possible (usually that's first surgery, second surgery three months later and final office work two or three months after that). It would have been cheapest and I would have been even by now, but the reality of life dictated that I needed to wait to see if my new boob would soften up a little and fall a little so it would look more natural.

I hate to wait, but I waited. But I didn't know that when I was ready to move ahead again, I'd have this stupid problem.

I'll keep you posted.