Why Won't They Try?!

[GeauxForIt 659]

Ok, so I've had my 1st consultation with my surgeon on May 15 (last Tuesday). He's wonderful, thinks I'll do great and I'm scheduled for all of my appointment except the physical therapist already!

I have Aetna which will cover the surgery at 100% after my (very low) deductible of $250.00. Great, right?!

Well, here's the frustrating part. There is not an approved in-network provider in my area to do my sleeve surgery. (My surgeon is in-network for general surgery, but he files bariatric surgery under a different tax id.) Aetna told me that all they need to cover his fees as in-network (100%) vs. 70% after a $1250.00 deductible is for the insurance contact to call and submit a very simple form.

The insurance contact flat out REFUSES to even call them!! I'm shocked! Why wouldn't she even TRY to have the surgery covered for me? We're talking about ~$3000.00 out of my pocket versus $250.00!!

I can't understand this...any insight? Anyone else have a situation like this?

[Ms skinniness 3,003]

That is not their procedure. Talk with your doc and see if he'll contact the insurance company and make some arrangement with them. Insurance companies don't budge, but if the doc wants the business, he will step out of the box and call. If he doesn't, you might have to look for someone else. Might even have to drive further.

[LadyIvy 159]

I'm not sure what to tell you, but I hope this all gets settled soon. I am sorry that they are being such a PIA and making it difficult.

[GeauxForIt 659]

This is her email to me today, "After talking with my office manager, she said you have to use your out of network benefits since we are out of network. Sorry, let me know if you need anything else!"

I have the $%^& form...it's one page with about 5 blanks. That's it! I wanted to scream!!

If I change surgeons, will everything I've done so far "count" towards my requirements for Aetna? I'd hate to change b/c I trust this surgeon, but $3000 is A LOT of money for me to come up with.

I have my 1st official appointment in the 90 day process on June 19...should I talk to him then or try to get an appointment sooner? Any advise would be appreciated.

Thanks so much!

[chitowngirl 884]

The reason your doctor has 2 separate tax id numbers is because he doesn't want to contract with your insurance. The benefit of your doctor being out of network is that the surgeon does not have to accept aetna's rates. So Aetna will have to pay the surgeons fee and thus your insurance passes the expense to you. My suggestion check if there are any other contracted providers who could perform the procedure in your area.

[valdostaGA 149]

I've seen on another forum where people change surgeons all the time. I don't think its complicated at all.TRY it!!goodluck!

[GeauxForIt 659]

For some crazy reason, there are no in-network bariatric surgeons within 80 miles if me!