Insurance - the latest thing giving me panic attacks

[buffalobillsfan]

Thanks to board support more than anything I am doing so much better after my surgery a week ago. Here is my latest dilemma though

Our medical insurance is BCBS of Illinois. My husband works for UPS Freight/Teamsters and although we have a PPO plan we have ZERO out of network benefits and no coverage. Zip, Zero! That benefit has always been the case even when Aetna or United was the provider. When I had my DS I paid out of pocket for Dr Rabkin's surgeon fees because he doesn't accept insurance. The hospital and everything else was covered by insurance.

When I went to the El Camino Hospital last Sunday for the bowel obstruction I told them that Dr Rabkin did my DS. They called him and then came in and asked me if I wanted to go to California Pacific Medical Center to be treated by him. Of course I was elated, said yes, and was whisked away by ambulance to CPMC.

I was so scared and in so much pain at the time but I do remember voicing my concern to Dr Rabkin about out of network, no coverage stuff. Of course he would have NO idea anything about insurance so now I'm not sure why I brought it up to him. I believe he said something about things are different when its an emergency. I was almost on my way out the door for surgery when I finished my registration.

Now I'm having panic attacks in my sleep worrying about this. I can't afford to pay for this surgery if the surgeon isn't covered. There was one DS surgeon (he does them RARELY) at the first hospital I was at. I think he might be in network. I really wanted Dr Rabkin because he knows my guts better than anyone.

Does anyone know how this will work? My husband said we will sell the house to pay it off if that is the case. This doesn't make me feel any better. This is why I am our household life manager!!! I'm a nervous wreck and it's ruining my appetite. Is it the hospital's responsibility to check insurance coverage prior to surgery and then inform you if something isn't covered? I signed a bunch of papers but had no idea what they were. I was on my way to surgery. Thanks again for your sage advice!

 

[DianaCox]

Get a copy of your Evidence of Coverage. That's the only way to tell.

But one thing should be clarified - a PPO in my experience means you have two or even three tiers of coverage - in network (sometimes distinguished between in-network in your chosen HMO-type environment, vs. a second tier of coverage with an in-network doctor or facility that is OUT of your HMO group [e.g., in my case, PAMF is my "HMO" group or preferred provider, but I see a BCBS doc for my gastroenterology needs, because I have been with him for a long time]). A separate category is doctors who don't take BCBS at all, and thus are truly out-of-network.

You did not have elective bariatric surgery - you had emergency surgery for a life-threatening bowel obstruction. You have a special medical/anatomical condition, which your in-network doctors determined justified a recommendation of transfer to a specialist at another facility. You were following medical advice in an emergency situation.

Also, Rabkin appears to be in network for general surgery even if he isn't for bariatric surgery. In fact, I have BCBS PPO through Carefirst BCBS of VA, and because I don't live in VA, I have a BlueCard (travel). When I look up Rabkin on the BCBS site (http://provider.bcbs.com/SearchResults), I get this:

John M Rabkin, MD
General Surgery

Sutter Pacific Medical
2340 Clay St
Fl 4
San Francisco, CA 94115
Ph: (415) 600-1063
Affiliations: Sutter Pacific Med

When I look up BlueCard, I found this, which is the BCBSIL version:
http://www.bcbsil.com/pdf/education/wellness/bluecard_member_flyer.pdf

I assume SOMEONE made some phone calls at CPMC and from Rabkin's office before you were treated - call your insurance company and ask.

 

[buffalobillsfan]

Get a copy of your Evidence of Coverage. That's the only way to tell.

But one thing should be clarified - a PPO in my experience means you have two or even three tiers of coverage - in network (sometimes distinguished between in-network in your chosen HMO-type environment, vs. a second tier of coverage with an in-network doctor or facility that is OUT of your HMO group [e.g., in my case, PAMF is my "HMO" group or preferred provider, but I see a BCBS doc for my gastroenterology needs, because I have been with him for a long time]). A separate category is doctors who don't take BCBS at all, and thus are truly out-of-network.

You did not have elective bariatric surgery - you had emergency surgery for a life-threatening bowel obstruction. You have a special medical/anatomical condition, which your in-network doctors determined justified a recommendation of transfer to a specialist at another facility. You were following medical advice in an emergency situation.

Also, Rabkin appears to be in network for general surgery even if he isn't for bariatric surgery. In fact, I have BCBS PPO through Carefirst BCBS of VA, and because I don't live in VA, I have a BlueCard (travel). When I look up Rabkin on the BCBS site (http://provider.bcbs.com/SearchResults), I get this:

John M Rabkin, MD
General Surgery

Sutter Pacific Medical
2340 Clay St
Fl 4
San Francisco, CA 94115
Ph: (415) 600-1063
Affiliations: Sutter Pacific Med

When I look up BlueCard, I found this, which is the BCBSIL version:
http://www.bcbsil.com/pdf/education/wellness/bluecard_member_flyer.pdf

I assume SOMEONE made some phone calls at CPMC and from Rabkin's office before you were treated - call your insurance company and ask.

ohmygodohmygodohmygod. So happy! I just looked on the provide list and Dr Rabkin was on there!!!!!! Why didn't I think to look? I never thought of him as a General Surgeon! I love you Diana! I can rest now. I can only repay you in another kitten. Which reminds me that you MIGHT want to look at the other post I did
http://bariatricfacts.org/forums/the-lounge.37/

 

[robs477]

Lady Di strikes again! So happy for you!