Long story short, I need another spinal fusion with my original surgeon. He is out of network and has always been. I have 80/20 out of network benefits, as i always have.
Provider is telling me I will have to pay majority of the procedure out of pocket as insurance is only covering 5k of it, which is devastating as I cannot possibly do that (nor can most). Last time, they paid 50k. Their explanation simply was "insurance has changed in the past few years, thats how it is."
This was the entire reason why I stay with out of network benefits. Why would they only pay 5k? That is way below the 80/20 benefits that I have. She explained to me that was the contracted rate. But if they still charge X over the 5k, wouldnt I still only be responsible for 20% of the X charge? Couldnt i still endorse the 80% check over to the provider?
Can someone dumb this down for me and explain how this can be? I tried calling my carrier, they said that doesnt sound right at all but couldn't give me any more info without preauth, and provider is refusing to send for preauth because they're non participating... I am very confused. How could i even have the surgery with my oon benefits without preauth in the first place? :(
I need this to be able to have a child. I have literally been crying the past few days (melodramatic I know). He is a neurosurgeon. The only other surgeons in my network who will perform this are only orthopedic surgeons - not neurosurgeons.
I'm just confused as to why this coverage is the way it is - 5k of a 50k+ surgery - and how i am responsible for 100% of the remainder of that when i have 80/20 oon benefits. Can someone explain?
https://ift.tt/eA8V8J Submitted June 29, 2018 at 10:17PM by the-red-witch https://ift.tt/2tE2Wbi