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Topic: NOLA - Out of pocket fees

Forum: Breast Reconstruction — Is it right for you? Discuss timing and various procedures and techniques.

Posted on: Aug 18, 2009 01:26PM

Dragonfly1976 wrote:

I talked to the ladies there at New Orleans to see what it would take for my surgeries to be done there. They said because they are out of network, that my out of pocket expenses would be 9,000.00 and a 1500.00 co-pay. Also there could be more expenses billed to me by the center. I don't know if these fees would be any different in Washington, if they work more closely with BC/BS. I am just heartbroken, I had wanted to go somewhere great and thought this would be a nice end to something so bad. Now I don't think I can go there, and if those fees are that high with a surgeon in Washington too then I'm screwed period!!!!

Dx 3/20/2009, 4cm, Stage II, Grade 3, 0/22 nodes, ER-/PR-, HER2-
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Aug 18, 2009 02:07PM Trishia wrote:

Did you speak to Lanita and fill out their financial packet?  They are giving you the WORST case scenario.  They will work with you and within your budget.  What is the worst case and what you actually pay are usually quite different.

Have you spoken with any of the docs in Washington?  Some of them maybe in network.  Also, you can appeal with your insurance company if there are no QUALIFIED DIEP surgeons in network.  They (insurance co) like to say no right off the get go! 

Dont' lose hope!!!  You are NOT screwed!  NOLA will work with you!!!  And if you have an in network doc in WA, you can still get a good result!   

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Aug 18, 2009 02:20PM Dragonfly1976 wrote:

I don't believe Washington is in network, but how do I know, give the insurance company specific doctors names or hospitals and see if it's covered?

 I suppose 10,500 may be the worst case scenario, but it's enough to make me not sure now what to do. Lenita at NOLA said they don't accept "in-network exceptions" made by insurance companies because they don't know what that means, they're costs could be higher than Oregon and something about reasonable and customary?

Dx 3/20/2009, 4cm, Stage II, Grade 3, 0/22 nodes, ER-/PR-, HER2-
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Aug 18, 2009 02:54PM Trishia wrote:

Your insurance company should have a list available of all the PS that are considered in network, and yes, call and ask them about the surgeons specfically.  Most times that have no idea the difference between a TRAM and a DIEP.  So make sure to be proactive with the name of the surgeons in WA that actually do the DIEP.  You could also call the facilities directly...UW and Virgina Mason both have DIEP surgeons.

Insurance companies have set 'reasonable and customary' charges for certain procedures.  The bad thing is that many of the them want to use the amount for a TRAM as the same thing as a DIEP.  This is NOT the case!!! 

NOLA will work with you!   I also sent you a PM.

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Aug 18, 2009 07:50PM PATTY50 wrote:

  • I am having stacked DIEP surgery in NYC with Dr. Robert Allan, he pioneered DIEP and many other surgeries. He performs surgeries in North Carolina, Lousianna and NYC. He is also out of network, but his office is working with me to have him considered in network for insurance purposes.  Basically I had to get a letter from a PS in network referring me to Dr. Allen because no one in my network does stacked DIEPs.  If the insurance co accepts him as in network, the most I have to pay is $2500.  His website is www.diepflap.com.  You can also call the office and speak to their insurance coordinator.  She and the rest of the staff have been very helpful. Good Luck:)
Dx 5/17/2007, IDC, 3cm, Stage IIB, Grade 3, 2/14 nodes, ER+/PR+, HER2+
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Aug 18, 2009 08:58PM Dragonfly1976 wrote:

Thank you Patty, I have filled out their form online to see if I'm a candidate and requested their nurse to contact me I guess is how it works? I wonder if they work with setting people up at the hope lodges? I know there is one in New Orleans and New York, and I think South Carolina?

Dx 3/20/2009, 4cm, Stage II, Grade 3, 0/22 nodes, ER-/PR-, HER2-
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Aug 18, 2009 09:14PM lovinmomma wrote:

I am readignt his with interest too, becasue I am in WA and I am looking to see if any ps do DIEPS here.

Kimberly 45 yo fighter Dx 10/1/2008, ILC, 6cm+, Stage IV, Grade 3, 26/26 nodes, mets, ER+/PR+, HER2- Chemotherapy 10/2/2008 Adriamycin (doxorubicin), Cytoxan (cyclophosphamide), Taxotere (docetaxel) Surgery 5/7/2009 Lymph node removal: Right, Sentinel, Underarm/Axillary; Mastectomy: Left, Right; Prophylactic ovary removal Hormonal Therapy 5/12/2009 Femara (letrozole) Surgery 7/10/2011 Reconstruction (left); Reconstruction (right) Chemotherapy 9/24/2012 Abraxane (albumin-bound or nab-paclitaxel) Chemotherapy 1/28/2013 Halaven (eribulin) Chemotherapy Xeloda (capecitabine)
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Aug 18, 2009 10:15PM SandyinSoCal wrote:

Whether you pay that much or your insurance works out so that you pay less, please remember that the CRBS in NOLA is home to the best reconstruction surgeons in the world.  I was prepared to pay up to $12,000 out of pocket for a much less-experienced (and less skilled, as it turned out) DIEP surgeon here in California, and that was only for stage I, and did not include his assistant.  I ended up with complications and the cosmetic outcome was destined to be mediocre, so I consider myself lucky to have found it necessary to leave home and go to NOLA for help.   I've had several (5) revision surgeries with Dr. DellaCroce, who has said many times that 90% of the result is set up in stage I.   It would have cost me far less in time, money, stress and unhappiness to have gone to NOLA first and paid $10-15,000 or whatever they would have charged me.   At the end of the day, you and only you can decide what it is worth to you to get the best result attainable.  This is one instance in which you just cannot look for bargains if you want the best.  Now, that being said, CRBS will most definitely work with you and your insurance company to get your share of the fees down to the absolute minimum.  It is a process and it takes time, but their insurance staff excel in what they do.

I am wonderfully made to do ExtraOrdinary things! (www.girleo.com) Dx 5/22/2007, IDC, <1cm, Stage I, Grade 3, 0/1 nodes, ER+/PR+, HER2-
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Aug 19, 2009 07:19AM Dragonfly1976 wrote:

I don't recall saying I was looking for a bargain, I figured out of pocket expenses would be there but not be that much. I am looking at all options still!

Dx 3/20/2009, 4cm, Stage II, Grade 3, 0/22 nodes, ER-/PR-, HER2-
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Aug 20, 2009 06:15PM PATTY50 wrote:

Hi Dragonfly,

Dr. Allen's office does set you up at the Hope Lodge if that's what you would like.  Me and my husband will be staying there.  Also wanted to say that Dr. Allen is one of the best along with the PS's from NOLA.  He actually taught them, so you should feel in good hands with him or at NOLA.

Dx 5/17/2007, IDC, 3cm, Stage IIB, Grade 3, 2/14 nodes, ER+/PR+, HER2+
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Aug 22, 2009 07:54AM SandyinSoCal wrote:

Hi Dragonfly,

I was making a generalized statement and I didn't mean that you had said anything about looking for a bargain.  CRBS will work with you on the out of pocket if you ask for help.

I am wonderfully made to do ExtraOrdinary things! (www.girleo.com) Dx 5/22/2007, IDC, <1cm, Stage I, Grade 3, 0/1 nodes, ER+/PR+, HER2-
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Aug 22, 2009 09:20AM Minnesota wrote:

There's also a Hope Lodge in New Orleans that ladies have stayed in.

(Pleomorphic LCIS) Dx 5/2006, LCIS, 4cm, Stage 0, 0/1 nodes, ER+/PR+, HER2-
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Aug 25, 2009 12:03PM Dragonfly1976 wrote:

You know, I'm beginning to wonder how this whole thing really works. Either no one wants to say what it costs them, or no one really knows, or it's a big top secret :) I guess I assumed that with the huge amount of ladies going to NOLA, that someone would have had a similar experience with "out-of network" and costs etc...

Dx 3/20/2009, 4cm, Stage II, Grade 3, 0/22 nodes, ER-/PR-, HER2-
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Aug 25, 2009 01:15PM Trishia wrote:

I told you in a PM what happened to me.  My insurance backed out of a signed contract and NOLA didn't balance bill me a thing when they could have.

Each person is different...because we all have different insurance companies and different financial situations.  What I may be able to afford maybe different than what you may be able to afford. 

I know I have talked to several ladies who have been and each one paid something different.  Some people don't want to put their financial matters out there on the internet, but are comfortable talking about it in person or over the phone.

No one is trying to hide anything.  There isn't some big consipiracy theory going on.  You are dealing with insurance companies who don't want to pay, and almost all of them being different plans from different states.  This isn't a 'one size fits all' facility or procedure.  

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Aug 25, 2009 01:53PM Dragonfly1976 wrote:

Um thanks for your imput, however I know I've talked with other ladies via pm who feel the same frustration I do with trying to get a grasp on the whole financial part of this and not getting anywhere. I wouldn't expect people to tell me down to the penny their bill, I just had hoped more would share their experiences as far as costs etc... Like I said with the huge amount of ladies that said they have been there, I made the mistake of assuming I'd get more of a response by asking for input.

Dx 3/20/2009, 4cm, Stage II, Grade 3, 0/22 nodes, ER-/PR-, HER2-
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Aug 25, 2009 02:52PM happy29 wrote:

Hi Dragonfly,

 I agree the financial aspect is SO frustrating. I think the biggest difference here is depending on what insurance you have. Even then, the plans may differ within the same insurance company. I was frustrated at first like you, and then realized that I had to do the phone calls with the doctors office and my own insurance company. It is a process. I started it about two and a half weeks ago and just found out today that I was denied an in- network exception.  This means I will have to pay my out of network costs. (which fortunately are low). The doctor's staff can help with insurance and I suggest that you get in writing what the most you will have to pay out of pocket then decide if it works for you. Out of pocket depends on your insurance benefits. Hope this helps. Good luck.

Dx 6/9/2009, DCIS, 1cm, Stage 0, Grade 2, 0/0 nodes
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Aug 25, 2009 03:20PM bennetts1 wrote:

Does anyone have a sample letter they could send me that they sent to their insurance company to get a in-network exception?  I am needing some guidance because I found out today that my insurance would not pay in-network so we are going to try to get the in-network exception.  I was told I had to get a surgeon, oncologist, or other doctor to write my insurance company a letter explaining why the DIEP procedure was a better procedure for me other than the procedures that my in-network doctors performed.  I personally know a surgeon who would be willing to help me out, but I thought if someone had a sample letter that had been successful...that would be wonderful!!!!  Thanks for any help you can provide!

Sandy

Dx 6/20/2008, 6cm+, Stage IIB, Grade 2, 1/12 nodes, ER+/PR+, HER2-
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Aug 25, 2009 03:44PM Ina wrote:

Dragonfly, 

I think this whole process is frustrating and it's really hard to be your own advocate.  I had a similar experience to yours, trying to get info about charges for DIEP surgery. The most frustrating thing for me was not being able to find out how much experience the surgeons have, since that is vitally important information. I looked into UW, Aldona Spiegel in Houston (She sounds great, but the breast surgeon with whom she was going to do my case would not work with my insurance at all), and Mayo in Phoenix.  I finally went to NOLA and had surgery with Dr. DellaCroce, not only because they have a great reputation and tons of experience, but because they promised me they would work with me financially. I trust they will keep their word. Dr. D. and the team there did great work. 

I stayed at the Hope Lodge for the first surgery, and was very happy with it.  The center set that up for me.  

I would recommend that you get as much information about finances in writing as possible. Everybody's situation is different, and we are all fighting various insurance giants.

Dx 12/6/2008, DCIS, Stage 0, Grade 3, 0/2 nodes, ER+/PR-
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Aug 25, 2009 03:47PM - edited Aug 25, 2009 03:50PM by bennetts1

This Post was deleted by bennetts1.
Dx 6/20/2008, 6cm+, Stage IIB, Grade 2, 1/12 nodes, ER+/PR+, HER2-
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Aug 25, 2009 03:57PM DFW wrote:

I had my surgery in NOLA. They were out of network for me also. There is a law that allows us to choose what type of recon we want and insurance has to pay. There was no one in my network that did DIEP and I was allowed to go to NOLA and I only paid personal expenses.

Insurance denied me, I appealed and was allowed to go. Don't give up!

Life without God is like an unsharpened pencil - it has no point.
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Aug 25, 2009 03:59PM DFW wrote:

Sandy

If no one shares their sample letter with you I will send you mine. I lost everything I had online when I had a virus so I will have to go to my files and dig it out and type it. Let me know if you don't receive one.

Life without God is like an unsharpened pencil - it has no point.
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Aug 25, 2009 05:32PM Trishia wrote:

There is a great sample letter on the Center's website!  Here is a link:

www.breastcenter.com/support/i... 

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Aug 25, 2009 07:03PM bennetts1 wrote:

Thanks Ladies!!!!

Dx 6/20/2008, 6cm+, Stage IIB, Grade 2, 1/12 nodes, ER+/PR+, HER2-
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Aug 25, 2009 07:42PM trainertam wrote:

I'm curious about the "law" of which you speak. I was told I was entitled to reconstruction but not "the kind I want". I am being given a complete run around and now I'm thinking of switching insurance during open enrollment, so your words really caught my ear.

Thanks!

Tammy Dx 6/26/2007, IDC, 1cm, Stage I, Grade 2, 0/3 nodes, ER+/PR+, HER2-
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Aug 25, 2009 08:13PM jseda wrote:

Hi Dragonfly:

Sorry for your bad news but this is a hugh factor with breast reconstruction. This is the issue I'd like to see more of from all women. This affects everyone in that we have to deal with the costs, not just the cancer. Yes, I do feel the costs for the DIEP procedure are way out of line. I know it is a very intricate procedure but way out of line in regards to similar procedures, such as open heart surgery.  I know that at the U of  Wash, DIEP is $65 K per breast for the first stage; does not include nipple/aerola reconstruction. I know I'm paying out of network as well and am not happy about the costs. I could go in network at Virginia Mason, but they are booked out 1 year to have this procedure done. Catch 22. Don't have any answers, just know that this needs to be addressed and women need to speak out. Might look for sights online that might offer financial aide for breast reconstruction post cancer. Anyone know of any such site?

Good luck

J.Seda

Dx 4/2009, DCIS, 3cm, Stage I, Grade 3, 0/2 nodes, ER-
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Aug 25, 2009 09:06PM Trishia wrote:

It's the Women's Health and Cancer Rights Act

SEC. 713. REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING
MASTECTOMIES.
(a) In General.--A group health plan, and a health insurance issuer providing health
insurance coverage in connection with a group health plan, that provides medical and
surgical benefits with respect to a mastectomy shall provide, in a case of a participant or
beneficiary who is receiving benefits in connection with a mastectomy and who elects
breast reconstruction in connection with such mastectomy, coverage for--
(1) all stages of reconstruction of the breast on which the mastectomy has been
performed;
(2) surgery and reconstruction of the other breast to produce a symmetrical appearance;
and
(3) prostheses and physical complications all stages of mastectomy, including
lymphedemas; in a manner determined in consultation with the attending physician and the
patient. Such coverage may be subject to annual deductibles and coinsurance provisions
as may be deemed appropriate and as are consistent with those established for other
benefits under the plan or coverage. Written notice of the availability of such coverage
shall be delivered to the participant upon enrollment and annually thereafter.
(b) Notice.--A group health plan, and a health insurance issuer providing health
insurance coverage in connection with a group health plan shall provide notice to each
participant and beneficiary under such plan regarding the coverage required by this section
in accordance with regulations promulgated by the Secretary. Such notice shall be in
writing and prominently positioned in any literature or correspondence made available or
distributed by the plan or issuer and shall be transmitted--
[[Page 

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Aug 25, 2009 11:07PM SandyinSoCal wrote:

Sometimes you just have to have a little bit of faith, ladies.  Understand that there are rules and laws and contracts with insurance companies, and you may not get what you want in writing, but if our doctors were not trustworthy enough to do what Trishia and Minnesota and I say they do for us on the financial end of things, why would we want to have surgery with them?  

I used the letter on the Center's site referenced above as a second appeal letter, and got my insurance company to pay my first surgeon in full for stage I, despite him being out-of-network.  I had already given him $2500, and did not get that back, but had expected to owe him about $12,000.   

Please understand that some things just cannot be posted on a public bulletin board.  There is no need for frustration---just PM some of us who've been to NOLA and we can discuss this further off the forum.

I am wonderfully made to do ExtraOrdinary things! (www.girleo.com) Dx 5/22/2007, IDC, <1cm, Stage I, Grade 3, 0/1 nodes, ER+/PR+, HER2-
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Aug 26, 2009 08:03AM TammyLou wrote:

Dragonfly,

 I think an important aspect to your question is WHEN did you have reconstruction, in conjunction with how much out of pocket.

 My own guess is that as DIEP /microsurgical construction has become more readily available by other microsurgeons, insurance companies are becoming less inclined to pay for private doctors.

 I don't know their charges, etc., but it seems unlikely to me that private doctors can price match the surgical bills presented by University type hospitals.  Most universities are subsidized by grants, etc., so they can afford to accept what insurance companies will pay.

 Whatever people's opinions are, there is little data that actually supports a big difference in outcomes between microsurgical free trams and DIEPs. 

 However, there are significant differences between pedicled trams and the microsurgical procedures (MS Free TRAMS, DIEPS) in terms of donor site morbidity...damage to the rectus abdominis particularly in the case of bi-lateral reconstructions.  And that fact is well-documented.

I'm sure I'm going to be attacked for this...but, from my reading, I would encourage you to have about $10,000 squirrelled away before going to a private doctor for reconstruction.  Maybe you will be one of the lucky ones...maybe something can be worked out to your advantage and you don't have to pay that much, but that is a common figure that I have seen tossed around.

 One of the ladies that I know needed bi-lateral GAPs...definitely a challenge to find a microsurgeon, and seriously a challenge to find one that will do both sides in one surgery.  She sold her car and used the money to finance the surgery...then, she bought a new one at a very low interest rate and payments that she could afford. 

It is understandable that people have emotionally, physically and financially invested in their reconstructions and would encourage you to go to the "best" microsurgeons in the country; however, it is worth keeping in mind that there are thousands of women who have had very good microsurgical reconstructions at multiple facilities across the country.

tl

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Aug 26, 2009 07:09PM jseda wrote:

You can always appeal your insurance co. I'd personally appeal their decision and tell them its not acceptable. Ask your PS to help document the best case scenario for your care vs their choice. I don't know your case so can't give specifics, but I'm sure your surgeon would be more than available to help. Its probably not their first time doing this.Worse thing that can happen is that they say no. I just went through this myself and the appeal overturned their decision and as a consequence will be able to have what my PS recommends. Just takes a little more effort, like everything. Good luck

J. Seda

Dx 4/2009, DCIS, 3cm, Stage I, Grade 3, 0/2 nodes, ER-
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Aug 26, 2009 10:58PM SandyinSoCal wrote:

Before you consider a university setting, consider that you may have less-than-seasoned surgeons working on you.  Due to the complexity of DIEP and GAP reconstruction, it is my understanding that Medicare has coded them up there with the most complex of all surgeries---a kidney transplant.  This is not surgery you want to have with less than a highly experienced and very artistic surgeon.  I have learned through my own experience that how it is set up in stage I determines how lovely the outcome.    It is worth every penny to go to the best; worth a few days away from family; worth any hassle of traveling.   I stayed near home and have paid the price---five "stage II" surgeries fixing up the work of a doctor who does DIEP but is not one of the best at it.  I just thank God both flaps survived with him as my surgeon, and that I heard about NOLA prior to subjecting myself to stage II with him.

I am wonderfully made to do ExtraOrdinary things! (www.girleo.com) Dx 5/22/2007, IDC, <1cm, Stage I, Grade 3, 0/1 nodes, ER+/PR+, HER2-
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Aug 27, 2009 05:18AM - edited Aug 27, 2009 05:19AM by TammyLou

I understand what you are saying.  I'm sorry that your initial reconstrucion didn't do well.

 It is very important to know how many repetitions the microsurgeon has had.  Repetitions tend to reduce risk of complications.

I can speak of my own doctor, R. Jobe Fix.  Doctor Fix is a microsurgeon at UAB - University of Alabama at Birmingham.  (Kirklin Clinic)

Doctor Fix's failure rate with MS-2 Free Tram / DIEP is less than 1/2 percent.

He is one of America's Top Docs.

 2% failure rate or less is considered good.  You want a microsurgeon who has done at least 100 flaps.

Flaps are a complicated procedure.  Top surgeons across the country have individual instances of less than optimal outcomes.

It sucks when it's you...for sure.

There are competent, well-practiced microsurgeons out there.

tl

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