BCBS "Allowable" Nightmare

[way2slow]

Hey all,
Yep, Im a first time surface hippy blogger and just now starting down the HRS road. My first planning obstacle is trying to determine what my cost will be for resurfacing when using an out of network Doc. I have BCBS PPO and they pay 70% of ALLOWABLE. Hate that word b/c its a black hole. I ver tried to get BCBS to give me what the allowable cost is for HRS. They wont. They say that since I reside in Oklahoma and the services rendered/operation will occur in Wisonsin, they dont know allowables nor can I call BCBS in Wisconsin to find out.  And BCBS in Oklahoma will not call either.. of course. So I guess I m just venting with this blog...sorry. Anybody else run into this "allowable" quagmire with BCBS? Kevin       

[Dayton96]

Kevin:

I've got BCBS of Ohio.  I'm trying to figure out how much a resurface would cost with Dr. Roberson.  Sometime this week I thought I would call his office and talk to the business manger and see if they have some knowledge of what I would end up paying out-of-network.  If I get really, really lucky, they may have had a patient from Ohio with BCBS for federal employees who had to pay the same fees.  You just never know until you ask.  It's all part of narrowing down the choice for a surgeon.  Good luck and please share whatever information you come up with.

Mac

[way2slow]

Hey Mac,
Thanks for the reply. I called Dr Rogerson office today hoping to get the same type of info you mentioned, ie prior case info. Kathleen told me that they have a wide variance in values from $3k-11K in allowables for BCBS. She did not know why this is. So they may not be able to provide a good answer. If you have better luck please let me know. I did not press the issue that much since dr rogerson has not ok'd me as a candidate for HRS. He reviewed my xrays, and now wants a CT scan. It appears I have holy femurs .   K

[Dayton96]

Kevin:

I will.  I also wanted to ask Dr. Rogerson's office if there were other insurance plans, under the federal employees program, that might be known for providing better coverage.  We have open season coming up at the end of the year and I could switch plans.  I'm planning on getting the surgery done this winter, but I haven't picked a surgeon yet.  Some of the best, like Dr. Su and Dr. Rogerson, are not covered by my plan.  Dr. Gross of SC is though and he is one of my top three choices.  That is a different topic though. 

Mac 

[mari]

I too have BCBS and originally checked with Dr. Rogerson's office in WI because I live in MN.  But since he was not in my network I started looking elswhere and discovered Dr. Gross in SC.  He was in my network so I sent my x-rays there and he very kindly called me and answered all my questions.  The rest is history.  I had my surgery there and was very pleased with Dr. Gross and his staff, the hospital, and the coverage I received from BCBS. I would highly recommend that you consider having your surgery there.

[Tommy]

Kevin,
      As a fellow Oklahoma hippy I can tell you that the word "ALLOWABLE" was a loop hole for my insurance to not pay, specifically the cost of the implant and the anesthesiologist. I tried to find the same info as you since I used a out of network hospital here in Oklahoma.   
                                          Tommy

[way2slow]

Mari,
Thanks for the reply. Yes, I too have looked at Dr Gross and he is IN NETWORK for me. I ve not checked to see if Midland Orthopaedic hospital is in network but will do so. As you know, Gross is not a BHR guy and the BIOMET prosthesis he uses has a much higher failure rate than BHR if you look at the Australian Registry info. I m sure there are a ton of factors as to why this is and doc ability may be a factor. So this failure rate may not pertain to Dr Gross. Ive heard only great things about his surgical abilities. And I know he takes on less than optimal cases that others might be squeamish. kevin

[resurface]

Kevin

I thought based upon past posts that Dr. Gross was using the BHR and has since developed or was part of the development team at Biomet.  If so, he is experienced with both systems.  If you request the BHR he may do it for you.  Good luck...

Resurface.

[stevejco]

Hi Kevin  I'm also in the planning stages of bi-lateral HRs and have bc/bs federal employees plan.  I'm resopnsible for 15% of the costs when I use a prefered provider. My plan has a catostrophic clause that states that my deductable can't exceed 5,000.00 per calender year. You may save money by having your surgery towards the end of the year depending on your deductable balance. My deductable fees ytd have been $1,500.00 so I would be charged up to but no more than $3,500.00 for my surgical costs. Keep in mind that any and all services provided during you hospital stay( anesthesia, EKG, x-rays and labs ect.) must be administered by prefered providers as well or you would be responsible for paying at least a portion of them depending on your coverage. Check your plan and ask your doc to use only prefered providers when possible and that may reduce your costs.  Also if you can have your surgery at the begining of the week you may be better off as some hospitals contract these services out during weekends to reduce staffing and these contracts might not be with prefered providers. My bc/bs rep was nice enough to tip me off to these possible savings. Your plan might be very different so make sure you look into it.  Good Luck,  Steve

[DirkV]

If you have an annual cap on out of pocket costs, you also might want to consider scheduling surgery early in the year. I did that, so that I could have follow-ups, phy therapy, etc. all essentially free (after maxing out my costs for staged bilateral in Feb and March).
Good luck!
-Dirk

[emichel]

Wasn't sure whether to start a new thread, because my question is a little different.  I am looking at bilateral resurfacing or replacement, which I go with is not relevant to this discussion.  At first I was happy because I have a good insurance plan, Premera Blue Cross Heritage Plus (Wa state).  It's supposed to be $2,500 a year out of pocket maximum, not counting copayments and $500 deductible.  I thought that was great, since $2500 will go fast with hospitalization and surgery.  However, reading the fine print, it says something about "customary and allowable expenses" (I don't remember the exact wording).  Does that mean that if the "providers" charge more than average, I will have to pay out of pocket, even after $2500?  If so, I am in deep doo doo.  :-(    -- Eileen

[pc]

Have the doctor and hospital call the insurance and they will let you know the total out of pocket expense. I was surprised that my insurance actually covered more than I had expected. Good luck! Rick

[Luann]

I have BCBS of Oregon (through Teamsters Union Plan) and after I chose my surgeon, hospital, etc, I called (do it yourself, do not rely on the "people behind the desk") my insurance company and asked them personally what my maxium out of pocket expense would be. They were able to tell me, after tallying it all up, the exact amount. After all the bills were done, I would say they were very accurate. I also always get the person's name on the phone who counseled me (not sure why, but something tells me it's a good idea!). Hope this helps somebody! Lu

[emichel]

Way2slow, does your plan have an annual out-of-pocket maximum that you have to pay?  I'm no insurance expert, but it seems to me if you have a reasonable out-of-pocket maximum you can't lose.  With my plan they pay 80% in network, and only 60% for out of network, but it seems to me that either way you will reach the out-of-pocket maximum pretty quickly, and then it doesn't matter what they charge. 

[FlbrkMike]

I just got scheduled for bilateral BHRs, one in February and one in March, so now I'm starting to get interested in the cost and insurance aspects.

I have a "high deductible" (HSA) plan with Blue Shield of California.  Family deductible is $4,000 and then 20% copay up to the $7,000 annual out of pocket limit.  I hope everything is covered under this policy and I will be calling tomorrow to make sure.  If it's not I'm in trouble...  

I already have about $4,000 in my HSA so I'll have to come up with another $3,000 pre-tax.  $7,000 is nothing to sneeze at but I figure that two surgeries and all the followups will be covered, and all other medical costs for the year (including some expensive cholesterol and hypertension meds) will be beyond the maximum.  That makes it a pretty good deal for a procedure that will transform me from Grandpa McCoy to Cam Newton in a matter of months.