Question:
Ins. is covering everything doctor, surgery, ect... Hospital refuses to accept my

ins. This is the only hospital my doctor works out of.. So how can the doctor be on board with the insurance but the hospital isn't.. Has anyone been turned down because of this? Can I do anything to get the hospital to reconsider? My ins. company said I could change doctors but, this doctor does it lap-rny and the other do it open...So it's either open and have it done at another hospital or try to fight this and have it done lap......HELP    — M. (Annette) P. (posted on July 9, 2003)

July 9, 2003
Yes, it is not uncommon to have at least one of the providers not be on your insurance - it is not anybody's fault and nobody is doing anything they aren't supposed to - it just works out that way sometimes. Besides changing docs, you have 2 choices: Try to see if your insurance company and the hopsital will work out a one-time contractual agreement in your case. Sometimes a hospital will take a discount on a case-by-case basis, and your insurance company may be able to negotiate a deal with them. The other is to see if your surgeon will do the case at the covered hospital. Now he would have to get special approval for a one-time case - they can do this - but I would be surprised if your surgeon was willing to deal with this for you - it is really above and beyond the call of duty on his part. If he is only on staff at one hospital, it is probably because he likes it that way; most are on more than one. Your best bet would be to contact the Utilization Review department at your insurance company, explain the situation, and see if they can have someone contact the hospital's business manager to attempt a special agreement. An example might be: We'll pay at 80% instead of 60% if you take a 15% write off for the charges (they don't charge the patient for the write off); or our patient won't be able to use your facility due to the financial hardship of the 20% difference. Sometimes they'd rather take a 15% discount then get 100% of nothin - sometimes they wouldn't.
   — bethybb

July 10, 2003
If your insurance has out of network benefits, then there is probably little you can do. However, you may be able to get your insurance company to cover the surgery at an out of network hospital on appeal. Here's the spin: Your surgeon does a procedure that is not available at an in-network facility. (We call it a "network inadequacy"). Also, by having the surgery done lap, even at an out of network hospital, you will likely be able to return to work sooner, and have less possibility of complications, such as incisional hernia and so forth. If you appeal to the insurance company and they agree that your argument is valid, they may go ahead and negotiate a rate with the hospital. Also, many insurance companies and hospitals buy into plans that offer discounts at non-network hospitals across the country. Negotiated rates may already be in place. Contact your customer service people at the insurance company, and ask if they have Case Managers. If so, see if one can take your case, so you will have someone to contact directly. Good luck!
   — koogy